Travel Questionnaire Travel Questionnaire Travel Risk Assessment FormPlease only complete the below form once you have booked an appointment with our travel Nurse. Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Please try to give us prior notice (preferably 6 weeks).Title Mr Mrs Miss Ms Mx Dr Other Full NameDate of Birth Day Month Year Address Street Address Address Line 2 City Postcode Contact NumberEmail Enter Email Confirm Email Destination(s)Please supply information about your trip in the sections belowUK Departure Date Day Month Year Total duration of trip (in days)Please enter a number from 0 to 99999.1st Country being visitedExact Location or RegionCity or RuralPlease selectCityRuralLength of stay (include stopover destinations)2nd Country being visited OptionalExact Location or Region OptionalCity or Rural OptionalPlease selectCityRuralLength of Stay (include stopover destinations) Optional3rd Country being visited OptionalExact Location or Region OptionalCity or Rural OptionalPlease selectCityRuralLength of Stay OptionalFurther InformationHave you taken out travel insurance for this trip?Do you plan to Travel abroad again in the future?Type of travel and purpose of trip – Please tick all that apply Business trip Holiday Expatriate Volunteer Work Healthcare Worker Staying in Hotel Cruise Ship Safari Pilgrimage Medical Tourism Backpacking Camping/ Hotels Adventure Diving Visiting Friends/ Family Please provide deatils of your personal medical historyAre you fit and well today? Yes No Do you have any allergies including food, Latex, Medication? Yes No If you answered yes to the above question please state allergies OptionalSevere reaction to a vaccine before? Yes No Tendency to faint with Injections? Yes No Any Surgical Procedures in the past, including eg. your Spleen or Thymus Gland Removed Yes No If you answered yes to the above question please give details OptionalRecent chemotherapy/ radiotherapy/ Organ transplant? Yes No Anaemia Yes No Bleeding/ Clotting disorders (Including History of DVT) Yes No Diabetes Yes No Disability Yes No Heart Disease (e.g.Angina, High Blood Pressure) Yes No Epilepsy/ Seizures Yes No Gastrointestinal (Stomach) Complaints Yes No Liver and or Kidney Problems Yes No HIV/ AIDS Yes No Immune System Condition Yes No Mental Health issues (including anxiety, depression) Yes No Mental Health issues (including anxiety, depression) Yes No Neurological (Nervous System) Illness Yes No Respiratory (lung) disease Yes No Rheumatology (joint) conditions Yes No Spleen Problems Yes No Any other Conditions? OptionalWomen OnlyAre you Preganant? Yes No Are you Breast feeding? Yes No Are you planning pregnancy while away? Yes No Are you currently taking any medication (including prescribed, purchased or a contreceptive pill?) Yes No If you answered yes to the above question please give details OptionalPlease supply information on any Vaccines or Malaria tablets taken in the pastTetanus/ Polio/ Diphtheria OptionalTyphoid OptionalCholera OptionalRabies OptionalMalaria Tablets OptionalYellow Fever OptionalMMR OptionalHepatitis A OptionalHepatitis B OptionalJapanese Encephalitis OptionalBCG OptionalInfluenza OptionalPneumococcal OptionalMeningitis OptionalTick Borne Encephalitis OptionalOther OptionalAny Additional Information (Please outline Below) Optional