Courtenay House Surgery
Travel Questionnaire
GOING ABROAD ON HOLIDAY OR BUSINESS?
You may need travel vaccinations, depending on the country/countries you intend to visit.
To help us advise you on the protection you need, please see the practice nurse at least 8
weeks before you travel and ideally 12 weeks ahead.
Please complete and return this form as soon as possible and make your travel
appointment, leaving a week in between returning the form and your appointment.
PLEASE NOTE we do not provide Yellow Fever * see over
We can provide Hep B for a charge of £25 per dose, course of 3 doses, payable in advance
Your Details
Name:
Male / Female
Date of Birth:
Address:
Home:
Mobile:
Where and When
Please indicate below which countries you intend to visit, including any stopovers however brief. Please also
state the location you will be staying in and how long you will be staying in each and order of your stay.
Country
Location
Length of stay
Comments (please give any extra information you think relevant)
Type of Trip
Please circle the descriptions that best describe your trip, if other please complete section below
1. Type of trip
 Business
2. Holiday type
 Package/camping
3. Accommodation  Hotel
4. Travelling
 Alone
5. Area
 Urban
6. Activities
 Safari/jungle
Other (as circled above, please give details)
 Pleasure
 self-organised/cruise
 Relatives/family home
 Family/friend
 Rural
 Adventure
Please turn over - page 1 of 2
 Other
 Backpacking
 Other
 Group
 Altitude
 Other
Vaccination History
Have you ever had any of the following vaccinations/malaria tablets and if so when (please tick)?
 Tetanus
 Typhoid
 Meningitis
 Rabies
 Other
 Malaria Tablets
 Polio
 Hepatitis A
 Yellow Fever
 Jap B Enceph
 Diphtheria
 Hepatitis B
 Influenza
 Tick Borne
Personal Medical Information
Are you allergic to anything (please give details)
 Yes  No
Are you taking any medication (please give details)
 Yes  No
Have you ever had a serious reaction to a vaccine given before?
Does having an injection make you feel faint?
Are you suffering from heart disease or other chronic illness
Do you or any close family members have epilepsy?
Do you have any history of mental illness or depression?
Have you recently had radiotherapy/chemotherapy/steroid treatment?
Women only – are you pregnant, planning pregnancy or breast feeding?
Have you taken out or will you be taking out travel insurance?
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
Please give any further details that may be relevant
Is there anything specific that you would to discuss at your travel appointment?
Patient consent
I hereby confirm that the information supplied is given to the best of my knowledge
Signed
Date
* Alternate travel clinics:Health Station, Hitchin – 01462 459595
Masta Clinic, Cambridge - 0330 100 4127
Courtenay House Doctors Surgery, Bancroft Court, Hitchin, Herts, SG5 1LH
01462 434239
courtenay.housesurgery@nhs.net
Version 1 – last updated 14/01/2016
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