Patient Details Name Date of birth Address NHS number Home Telephone Mobile Telephone Travel Itinerary Dates Country Exact location/region City or Rural Length of Stay 1. 2. 3. 4. Travel Information (please tick all that apply) Type Holiday Business trip Volunteer work Visiting friends/family □ □ □ □ Expatriate Cruise ship Healthcare worker Pilgrimage □ □ □ □ Accommodation Camping Hostels Friends/Family □ □ □ □ Safari Diving Adventure Activities □ □ □ Additional information: Medical History Yes No Details Are you fit and well today Severe reaction to a vaccine before Tendency to with injections Any surgical operations in the past, including e.g. your spleen or thymus gland removed Recent chemotherapy/radiotherapy/organ transplant Anaemia Bleeding /clotting disorders (including history of DVT) disease (e.g. angina, high blood pressure) Diabetes Disability Epilepsy/seizures Gastrointestinal (stomach) complaints Liver and or kidney problems HIV/AIDS Immune system condition Mental health issues (including anxiety, depression) Neurological (nervous system) illness Respiratory (lung) disease Rheumatology (joint) conditions Spleen problems Any other conditions? only Are you pregnant? Are you breast feeding? Are you planning pregnancy while away?
Patient Details Name Date of birth Address NHS number Home Telephone Mobile Telephone Travel Itinerary Dates Country Exact location/region City or Rural Length of Stay 1. 2. 3. 4. Travel Information (please tick all that apply) Type □ Holiday □ Business trip □ Volunteer work □ Visiting friends/family □ Expatriate □ Cruise ship □ Healthcare worker □ Pilgrimage Accommodation □ □ Camping □ Hostels □ Friends/Family Activities □ Safari □ Diving □ Adventure Additional information: Medical History Yes No Details Are you fit and well today Severe reaction to a vaccine before Tendency to with injections Any surgical operations in the past, including e.g. your spleen or thymus gland removed Recent chemotherapy/radiotherapy/organ transplant Anaemia Bleeding /clotting disorders (including history of DVT) disease (e.g. angina, high blood pressure) Diabetes Disability Epilepsy/seizures Gastrointestinal (stomach) complaints Liver and or kidney problems HIV/AIDS Immune system condition Mental health issues (including anxiety, depression) Neurological (nervous system) illness Respiratory (lung) disease Rheumatology (joint) conditions Spleen problems Any other conditions? only Are you pregnant? Are you breast feeding? Are you planning pregnancy while away?
Travel%20Questionaire%20Oct%2018v2.docx