Travel Questionnaire

Once you have completed and submitted this form, please give the Surgery a call in approximately five days to see what vaccinations you may be due.  This will give the Nursing Team enough time to review your previous vaccinations and see what is overdue or needed.  Many thanks.

Gender

Please provide details of your trip including dates and departure

Purpose of trip
Type of trip
Accommodation
Travelling
Location type
Activity type

Personal medical history

Please select the following that apply
Have you ever had any of the following vaccinations / tablets?