Travel Questionnaire

Once you have completed the form below please contact the surgery to make your appointment.

Please note there is a charge for several of the injections, please bring cash or cheque for your appointment.

Personal Details

Your name:

Date of birth:

Gender:

Contact Number:

Email address:

Dates of Trip

Date of departure:

Return date or overall length of trip:

Itinerary and purpose of visit:

Country to be visited and length of stay

Away from medical help at destination, if so, how remote:

Personal Medical History

(if not applicable please leave empty)

Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder.

List any current or repeat medications:

Do you have any allergies for example to eggs, antibiotics, nuts?

Have you ever had a serious reaction to a vaccine given to you before?

Does having an injection make you feel faint?

Do you or any close family members have epilepsy?

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

Have you recently undergone radiotherpy, chemotherapy or steroid treatment?

Women only: Are you pregnant or planning pregnancy or breast feeding?

Have you taken out insurance? If you have a medical condition, have you informed the insurance company about this?

Please give any further information that may be relevant, including any future travel plans:

Disclaimer

For discussion when risk assesment is performed within your appointment: I have no reason to think that I might be pregnant. I have recieved information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questi

Do you accept the above statement? please note the form will not send without this confirmation.

Yes

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Park Medical • Great James Street Health Centre, Great James Street, Derry, BT48 7DH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.