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Travel Questionnaire

Please complete and submit the form at least 3 months before your intended dates of travel. If you prefer to download a hard copy to complete and hand in to reception, you can print it off here. In a few days, please make an appointment to see the nurse to go through the details.

Date of DepartureDate of Return
CountryDuration in daysCiy or Rural
Type of Travel and purpose of trip - tick all that apply
Please supply details of your personal medical history

Women Only


Type of ImmunisationDate if known
Name of Antimalarial TabletDate if KnownAny Side effects?

We may be in touch with you in relation to the information submitted. All Information submitted through secure forms is encrypted and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy. This information does not leave the EEA. For the purposes of GDPR, St Wulfstan Surgery is the data controller and IPEGS is the data processor. Their privacy notices can be read at