Travel Questionnaire

IT IS YOUR RESPONSIBILITY TO MAKE AN APPOINTMENT TO DISCUSS THIS FORM WITH A NURSE AFTER YOU SUBMIT THIS QUESTIONNAIRE. PLEASE ALLOW 48 HOURS BEFORE YOUR APPOINTMENT TO FILL IN THIS FORM, AND AT LEAST 6 WEEKS BEFORE YOU TRAVEL FOR YOUR APPOINTMENT.

If you are travelling outside of Europe for more than two weeks, you need to book a double appointment. 

You will need to fill out one form per person travelling. 

PLEASE NOTE WE DO NOT HAVE ANY LAST MINUTE APPOINTMENTS FOR TRAVEL. MAKE SURE YOU BOOK YOUR APPOITNMENT WITH PLENTY OF TIME, A MINIMUM OF 6 WEEKS BEFORE YOU TRAVEL. THIS IS YOUR RESPONSIBLITY. 

Personal details
Trip dates
Itinerary

* Availability of medical help: If you will be travelling to a place where medical help is not readily on hand, estimate how long it would take to reach a doctor.

ADD COUNTRY
Trip description (please tick all appropriate boxes)

Purpose of trip:

Type of trip:

Accommodation:

Travelling:

Location type:

Activity type:

Personal medical history
Vaccination history

Have you ever had any of the following vaccinations / tablets and if so, when?