Travel Questionnaire

Please note we only offer NHS travel vaccinations including Typhoid, Hepatitis A, Cholera and Tetanus (as part of combined Diphtheria, Tetanus, Polio). Any other travel vaccinations or malaria tablets will need to be purchased privately from Boots pharmacy, Staveley pharmacy or private travel clinic. We recommend you contact them up to 3 months before date of travel.

To establish the vaccinations you need, complete and return this form to the Practice. A nurse will assess your requirements and a receptionist will contact you to make an appointment.

Please access

Trip Dates


Trip Description

Personal Medical History

Vaccination History

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