Captain French Surgery | 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 fitfortravel.nhs.uk

If you are human, leave this field blank.

Name *

Sex

Female

Male

Date of Birth *

Postcode *

Daytime Tel *

Email *

Trip Dates

Departure *

Duration *

Itinerary

Country *

Duration *

Availability of Medical Help

Country

Duration

Availability of Medical Help

Country

Duration

Availability of Medical Help

Country

Duration

Availability of Medical Help

Country

Duration

Availability of Medical Help

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

Does having an injection cause you to feel faint?

Yes

Do you or any close family members have epilepsy?

Yes

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

Yes

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

Have you taken out travel insurance?

Yes

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

Yes

Are you pregnant, planning pregnancy or breast feeding?

Yes

Write below any further information that might be relevant

Vaccination History

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

Tetanus

Yes

Tetanus

Polio

Yes

Polio

Diphtheria

Yes

Diphtheria

Typhoid

Yes

Typhoid

Hepatitis A

Yes

Hepatitis A

Hepatitis B

Yes

Hepatitis B

Cholera

Yes

Cholera

Other

Travel Questionnaire

Trip Dates

Itinerary

Trip Description

Personal Medical History

Vaccination History