Travel vaccination questionnaire - Holmlands Medical Centre

Personal details

Name

First

Last

Date of birth

Sex

Male
Female

Email

Telephone

Travel dates

Departure date

Return date

Details about destination

How many countries/locations will you be visiting?

1
2
3

For example, if you are visiting three locations in one country, choose 3.

Do you plan to travel abroad again in the future?

Yes
No

Trip description

Type of holiday

Reason for trip

Business
Pleasure
Other

Primary accommodation

Hotel
Relative/family home
Other

Who I'm travelling with

Alone
With family/friend
In a group

Types of area I'll be staying at

Urban
Rural
Altitude

Planned activities

Safari
Adventure
Other

Personal medical history

Do you have any recent or past medical history of note? (i.e. diabetes, heart or lung conditions)

Yes
No

Do you have any current or repeat medications?

Yes
No

Do you have any allergies? (i.e. eggs, antibiotics, nuts, latex?)

Yes
No

Have you ever had a serious reaction to a vaccine given to you before?

Yes
No

Does having an injection make you feel faint?

Yes
No

Do you or any close family members have epilepsy?

Yes
No

Do you have any history of mental illness (i.e. depression, anxiety?)

Yes
No

Have you recently undergone radiotherapy, chemotherapy, or steroid treatment?

Yes
No

Are you pregnant or planning pregnancy or breastfeeding?

Yes
No

Have you taken out travel insurance and, if you have a medical condition, informed the insurance company about this?

Yes
No

Do you have any further medical information that may be relevant?

Vaccination history

Have you ever had any of the following vaccinations?

Do you remember when you had the vaccination(s) marked above?

If you have selected ‘Other’, please include the type of vaccination here as well as the date you think you last had it.

Have you ever taken malaria tablets?

Yes
No

Do you remember when you had the malaria tablets?