The Alexandra Practice
365 Wilbraham Road
Whalley Range
Manchester
M16 8NG
Travel Clinic Questionnaire – Registered Patient
Please note that we will not issue travel vaccinations to patients who are travelling within 7
days of this request.
Name
Address
Date of birth
Postcode
Telephone number
Male / Female
Trip details
Date of departure
Trip duration
Countries to be visited
Date of return
Medical history
Do you have any current or past medical history of note? (inc. diabetes, heart, lung conditions)?
Do you or any close family members have epilepsy?
Do you have any history of depression, anxiety or mental illness?
Are you taking any medication currently? Please list
Do you have any allergies? For example eggs, antibiotics, nuts?
Have you ever had a serious reaction to a vaccine?
Women only: are you pregnant, planning pregnancy or breastfeeding?
Do you have any allergies? For example eggs, antibiotics, nuts?
Have you taken out travel insurance?
If you have a medical condition, have you informed your travel insurance company?
The Alexandra Practice
365 Wilbraham Road
Whalley Range
Manchester
M16 8NG
Vaccination history: Have you ever had any of the following vaccinations? If so, please give
date
Tetanus
Polio
Typhoid
Hepatitis A
Meningitis
Yellow Fever
Rabies
Jap B Encephalitis
Have you ever taken Malaria tablets? If so, which and when
Diphtheria
Hepatitis B
Influenza
Tick Borne
To be completed with the nurse:
I have no reason to think that I might be pregnant. I have received information on 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 ____________________________
For official use only
Patient name _______________________
Travel risk assessment performed
Travel vaccines recommended for this trip
Yes
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Jap B Encephalitis
Other
Travel advice given
Food, water and personal
hygiene
Insect bite prevention
Insurance
Yes / No
No
Travellers diarrhoea
Hep B & HIV
Animal bites
Air travel
Accidents
Sun / heat protection
Malaria prevention advice and prophylaxis
Specify medication
Further information e.g. weight of child
Staff signature _______________________ Position __________________ Date __________