Travel Questionnaire

Going Away on Holiday or Business

PRIVATE AND CONFIDENTIAL

To help us advise you on the protection you need, please complete this online form at least eight weeks before you travel or alternatively if you prefer you can click here to download a pdf version of the form to fill in and hand it in at your local surgery. If travelling within two weeks please make the appointment now.

*Required Fields

Your Details
Name*
Address*
Date of Birth*	Please enter in format DD/MM/YYYY
Please ensure we have a daytime telephone number for our Practice Nurse to contact you.
Daytime Tel
Home Tel
Mobile Tel
Email
Do you consent to a message being left on your answer machine YES NO

Your Travel Details

Please complete details below. Our Practice Nurse will advise if there is a charge for the vaccine and malaria tablets.

COUNTRIES TO BE VISITED (with dates, including stopovers):

Country (Include area if known)	Date of arrival	Date of Departure	Type of Accomodation eg. Hotel, Camping, Backpacking

Please list any long-term medical conditions:

Have you suffered from depression or anxiety requiring medication?
YES NO

Please state any known allergies:

Any severe reaction to previous vaccinations?

Are taking the contraceptive pill, pregnant or planning a pregnancy in the next three months?
YES NO

Haxby Group Practice does not take any responsibility for the external interception or loss of this standard e-mail message.

Travel Questionnaire

Going Away on Holiday or Business

PRIVATE AND CONFIDENTIAL

Your Details

Your Travel Details