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Silloth Group Medical Practice

Travel Questionnaire

Personal Details

Name

Date of birth

Number

Email Address

Sex

Female

Male

Trip Dates

Departure

Duration

Itinerary

Country

Duration

Availability of medical help

Country

Duration

Availability of medical help

Country

Duration

Availability of medical help

Trip Description - please tick all appropriate boxes:

Purpose of Trip:

Business

Pleasure

Other

Type of Trip:

Package

Self-Organised

Backpacking

Camping

Cruise Ship

Trekking

Accommodation:

Hotel

Friends/Family

Other

Travelling:

Alone

With Friend/Family

In a Group

Location Type:

Urban

Rural

Altitude

Activity Type:

Safari

Adventure

Other

Personal Medical History

List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)

List all allergies that you have (eg. eggs, nuts, antibiotics)

If you have had a serious reaction to a vaccine in the past, which vaccine was it?

List all of your current medications (including oral contraception)

Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?

Yes

No

Does having an injection cause you to feel faint?

Yes

No

Do you or any close family members have epilepsy?

Yes

No

Do you have any history of mental illness including depression or anxiety?

Yes

No

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Have you taken out travel insurance?

Yes

No

If you have a medical condition, have you told your insurance company about it?

Yes

No

Are you pregnant, planning pregnancy or breast feeding?

Yes

No

Write below any further information that might be relevant

Vaccination History

Have you ever had any of the following vaccinations / tablets and if so, when?

Tetanus

Yes

No

If so when?

Diphtheria

Yes

No

If so when?

Polio

Yes

No

If so when?

Typhoid

Yes

No

If so when?

Hepatitis A

Yes

No

If so when?

Hepatitis B

Yes

No

If so when?

Meningitis

Yes

No

If so when?

Yellow Fever

Yes

No

If so when?

Influenza

Yes

No

If so when?

Rabies

Yes

No

If so when?

Jap B Enceph

Yes

No

If so when?

Tick Borne

Yes

No

If so when?

Other

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