Barcroft Medical Centre
Travel Questionnaire
This form will be discussed when risk assessment is performed during your
appointment.
Personal Details
Name:
Date of Birth:
Daytime Tel:
Sex:
Male
Female
Email:
Trip Dates
Departure Date:
(dd/mm/yyyy)
Duration:
Itinerary and Purpose of Visit
Country
Duration
of Stay
Availability of Medical
Help
Trip Description – please tick all the appropriate boxes
Purpose of Trip:
Business
Pleasure
Other
Type of Trip:
Package
Camping
Self-Organised
Cruise Ship
Backpacking
Trekking
Accommodation:
Hotel
Friends/Family
Other
Travelling:
Alone
Location Type:
Urban
Activity Type:
Safari
Personal Medical History
With
Friends/Family
Rural
Adventure
In a group
Altitude
Other
List all chronic medical conditions that you have (e.g. Diabetes, heart or lung conditions)
List all of the allergies that you have (e.g. eggs, nuts, antibiotics)
If you have had a serious reaction to any vaccines in the past, list them here:
List all of your current medications, including oral contraception
Have you recently suffered from any infection? (e.g. heavy cold,
flu or high temperature)
Does having an injection cause you to feel faint?
Do you or any close family members have epilepsy?
Do you have a history of mental illness, including depression or
anxiety?
Have you recently undergone radiotherapy, chemotherapy or
steroid treatment?
Have you taken out travel insurance?
If you have a medical condition, have you told your insurance
company about it?
Are you pregnant, planning pregnancy, or breast feeding?
Write below any further information that might be relevant.
Yes
No
Yes
Yes
Yes
No
No
No
Yes
No
Yes
Yes
No
No
Yes
No
Personal Details
Have you ever had any of the following vaccinations or tablets and, if so, when?
Tetanus
Yes
Date Given:
Polio
Yes
Date Given:
No
No
Diphtheria
Yes
Date Given:
Typhoid
Yes
Date Given:
No
No
Hepatitis A
Yes
Date Given:
Hepatitis B
Yes
Date Given:
Meningitis
Influenza
Jap B
Enceph
Malaria
Tablets
Other
(Please
List)
No
Yes
No
Yes
No
Yes
No
Yes
No
Vaccine:
Date Given:
Date Given:
Yellow
Fever
Rabies
Date Given:
Tick Borne
No
Yes
No
Yes
No
Yes
No
Date Given:
Date Given:
Date Given:
Date Given:
Date Given:
I have no reason to think that I might be pregnant. I have received information
about the risks and benefits of the vaccines recommended and have had the
opportunity to ask questions. I consent to the vaccines being given.
Signed ___________________________________
Date ___________________