Travel Vaccination Questionnaire

Travel Vaccination Questionnaire

Please complete this confidential questionnaire (please provide as detailed answers as possible).

Please only fill out the questions that apply to you, if the question is not relevant please click 'Next Step'.

To start click 'Next Step' below when you are ready to begin, this questionnaire will take around 10 minutes to complete.

Introduction
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Enter your name

Please enter your name, this information is essential for verifying your identity and maintaining accurate medical records.

*Title:
*Full name:
Personal Information
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Enter your date of birth

Please enter your date of birth this information is essential for verifying your identity and maintaining accurate medical records.

*Date of birth
Personal Information
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Please enter your address & postcode

Please ensure that you accurately fill out your address details. This information is crucial for our records and enables us to provide you with the best possible care and service.

*Address:
*Postcode:
Personal Information
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Please enter your phone number & email

Please enter your phone number and email address. This information is important for us to contact you promptly and send any necessary updates or communications regarding your care.

*Phone number:
*Email address:
Personal Information
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Please enter your travel dates

Please confirm your depature and return dates below.

Date of departure:
Date of return:
Travel Information
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Destionation(s)

Please enter your destination(s), please include all anticipated destinations.

Country*
Town/Region*
Environment*
Accommodation*
Duration*
Add Another Destination
Travel Information
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Purpose of travel

Please tick all that apply.

Other purpose of travel:
Travel Information
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Activities

Please tick all that apply.

Other activity:
Travel Information
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Who are you travelling with?
Travel Planning
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Who has organised the trip?
Other organiser:
Travel Planning
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Do you have any medical conditions that may affect your trip?
If Yes, please list:
Medical History
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Do you take any regular medication (including inhalers)?
If Yes, please list:
Medical History
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Do you have any allergies to the following?
Medication
Food
Other
If Yes to any, please list:
Medical History
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Women Only

Please skip these questions if they do not apply to you.

Are you pregnant, planning pregnancy or breast feeding?
Do you use an oral contraceptive pill?
If Yes, which one?
Womens Health
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As far as you are aware, did you receive the normal childhood vaccination schedule in the United Kingdom?
Vaccination History
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Have you ever had a reaction to any vaccines/immunisations?
If Yes, please state:
Vaccination History
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Past Vaccines

Please indicate which of the following vaccinations you have previously received. Please bring any record of vaccinations to your appointment.

Vaccine
Full Course
Booster
Date Received
DTP (Diphtheria, Tetanus, Polio)
TD (Tetanus, Diphtheria)
Tetanus alone
Typhoid
Hepatitis A
Hepatitis B
Meningococcal ACWY
Pneumococcal
Yellow Fever
Influenza (‘flu’)
Rabies
BCG (for tuberculosis)
Vaccination History
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Have you taken out travel health insurance?
Insurance
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Have you any additional questions?

Are there any specific questions relating to you health during travel that you would like answered?

If No, please click next step.
If Yes, please state:
Additional Info
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Confirm Submission

Please agree with the following statement and then click  'complete submission'

Confirmation
Complete
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