Travel Questionnaire – Saltaire and Windhill Medical Partnership

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This questionnaire should be filled in before seeing the Nurse for travel vaccinations. If you do not already have an appointment arranged with the Nurse, please complete the questionnaire and contact us to arrange an appointment. If you would prefer a printable version of the questionnaire please click here.

Travel Questionnaire

Name *

First

Last

Date of Birth *

Telephone Number *

Date of Departure *

The date that you travel

Date of return / Duration of travel *

The date you return from your travels, or the length of time you will be travelling for

Country(s) to be visited + duration of stay in each pace *

Please list each country you will be travelling to and the length of time you will be spending in each

The reason for travel is; *

Business
Pleasure
Visiting family and/or friends
Volunteer work
Other

The accommodation during my trip includes; *

Backpacking
Camping
Cruise Ship
Hostel
Hotel
Self-organised
With family/friends

I am travelling with; *

Alone
In a group
With family/friends

I am staying in areas which are; *

Urban
Rural
Altitude

Planned activities include; *

Adventure
Diving
Safari
Trekking
Water Sports
Other

Further Information

Please list any recent or relevant medical history of note;

Please list any current medications you take;

Please list any allergies;

WOMEN ONLY: Are you currently pregnant or breast feeding?

Yes
No

Have you taken out travel insurance?

Yes
No

If you have a medical condition, have you informed the insurance company about it?

Yes
No

Further information

Please give details of any vaccinations you have had with dates if known

Have you ever had any problems or adverse reactions to vaccinations? If so, please detail.

Are there any specific questions about your travel you would like answering?

Providing NHS Services

© 2023 Saltaire and Windhill Medical Partnership.

Home
About us
Virtual Surgery
Face to face & phone
Patient Participation Group
Find out more
Vacancies