Travel Vaccination Questionnaire

Name:
Date of Birth:
Contact Tel:
Email address:

Destinations – country & resort (Include any stopovers on the journey)

Reason for travel?

Holiday

Work

 

Date of travel:
Length of stay:

 

Type of accommodation (e.g. hotel, self catering, camping, backpacking, cruise etc. )

Please list any allergies

Please list all regular medication

Are you pregnant or might you be before you travel?

Yes

No

Date / time of appointment with nurse ( if made)

Any further information

 

If you have not already done so please make an appointment to see the practice nurse – leaving at least 10 working days from return of the form.