UNIVERSITY HEALTH SERVICE TRAVEL QUESTIONNAIRE
*Please also bring to your appointment: Your Vaccination Record (Childhood/ Travel) and Travel Itinerary*
Surname:_______________________________
First Name:___________________________________D.O.B___ / ___ / ____
dd/mm/yyyy)
Country of Birth:_____________________ In which country(s) did you spend your childhood?______________________
Did you complete your Childhood Immunisation?
YES
Date of Departure: ____ / ____ / ____ (dd/mm/yyyy)
Date of Return: ____ / ____ / ____ (dd/mm/yyyy)
Reason for Trip
Business / Work
Cruise / Tour
NO
Volunteer/Mission
Activities planned during travel
Rural / Remote
Diving
Urban / City
Snorkelling
Unsure
Visiting
Family/Friends
High Altitude
Surfing
Climbing
Camping
Caving
Type of travel
(eg Bus / Backpack)
Type of accommodation
Hotel/ Home Stay
Complete your travel Itinerary (preferably in Chronological order)
Country
Region:
Urban / Rural
Known Medical Conditions:
Length of stay
None
Yes
OR
Month of the
Year
Indicate Below
√
No
Heart Condition / Arrhythmia/
Palpitation
High Cholesterol
High Blood Pressure
Diabetes
Lung Condition
Asthma
Digestive Tract Problems
Heartburn / Acid Reflux
Discuss the following answers at Appointment
Yes
No
Yes
Seizure Disorder
Recent Cancer/ Leukaemia etc
Mental Health Condition
Skin Disease (Psoriasis etc)
Pregnant / Planning
Pregnancy
Organ/ Bone Marrow
transplant
Family History: DVT/ blood
clots
Blood Donor? Date of
donation
Recent Surgery or Planned
Surgery:
Immune System Disorder
Spleen removed / No spleen
Recent Chemotherapy
Recent Radiation
Other:
Medication Review
Yes
Drug / Medication / Other Allergies?
List:
Describe Reaction:
Do you take any Medication (ie Contraception / Over
the counter drugs/ herbal remedies)?
List:
Other:
Reviewed 2012.11.01
No
Yes
Have you previously taken Anti malarials?
List:
Did you have an adverse Reaction to them?
Describe Reaction:
No
No