Wells City Practice

Holiday Travel Questionnaire

HOLIDAY TRAVEL QUESTIONNAIRE

Important Information - Please Read

We are able to arrange most vaccinations required for foreign travel. Please consult the practice sufficiently early.

We need at least six weeks prior to departure to allow an appropriate interval between vaccinations if needed, and ensure that you are offered appropriate advice.

Please note that, although most travel vaccinations are available from the surgery, some drugs such as for malaria prophylaxis have to be purchased by the patient from a pharmacist (some on a private prescription). Please note travel advice and vaccinations including drugs for prophylaxis of infections when travelling are not free of charge on the NHS (we accept cash or cheques with a bankers card. We do not accept debit or credit cards).

Please note that we are NOT a YELLOW FEVER vaccination centre- we will advise you if you need this vaccine. Local Yellow Fever centres include Park Road Surgery 01749 334383 or Vine Surgery 01458 841122

PLEASE MAKE AN APPOINTMENT WITH THE TRAVEL NURSE Once you have completed following the holiday vaccination questionnaire.

Personal Details

Full Name	Enter Name
Date of Birth
Sex	Male Female
Address	Enter Address
Post Code	Enter PostCode
Home Tel	Enter Telephone
Email Address	Enter EmailInvalid format

Itinerary and purpose of visit

Date of Departure
Date of Return
Countries to be visited (including stop overs)	1
	2
	3
Length of Stay		Days
Type of Trip		Holiday Business Other
Accommodation		Hotel Private House Camping/Back packing

Medical History

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions).	No Yes If yes provide details:
Please list any current or repeat medications
Do you have any allergies (eg. Eggs, antibiotics, nuts etc)
Have you ever had a serious reaction to a vaccine given to you before?	No Yes If yes provide details:
Does having an injection make you feel faint?	No Yes
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?	No Yes If yes provide details:
Women only: Are you pregnant or planning pregnancy or breast-feeding?	No Yes
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?	No Yes
Please add any further information which you think may be relevant:

	Your Full Name is missing Your Address is missing Your Postcode is missing Your Telephone number is missing Your Email Address is missing Your Email Address format is invalid
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