Travel Immunisations | Webform Portal - Paperless Mission Control

Travel Questionnaire

Please complete and submit the form at least 3 months before your intended dates of travel.

To download a hard copy to complete and hand it to reception, please print it off here.

Once we have received the completed form a member of the Reception team will contact you within 28 days to book an appointment with the nurse to go through the details. Please note if your travel arrangements are within the next 28 days there is a chance we will not be able to fulfill your request and would recommend you use a private travel vaccination company.

Full Name *

Date of Birth *

email *

Contact telephone number *

Gender *

Departure and Return Dates

Date of Departure	Date of Return

Countries to be Visited and Duration of Stay

Any other places, dates and city/rural

Travel Insurance

I have taken out travel insurance I have NOT taken out travel insurance

Future Travel Plans

I do plan to travel abroad again in the future I do NOT plan to travel abroad again in the future

Type of Travel and purpose of trip - tick all that apply

Type of Travel and purpose of trip - tick all that apply
Holiday Business Expatriate Volunteer work Healthcare work	Staying in Hotel Cruise Ship Safari Pilgrimage Medical Tourism	Backpacking Camping/Hostels Adventure Diving Visiting Friends/Family

Past Medical History

Please supply details of your personal medical history
Severe reaction to a vaccine before Any surgical operations in the past (including spleen or thymus) Recent chemotherapy radiotherapy organ transplant Bleeding or clotting disorder (including history of DVT) Any Allergies including food or latex or medication	Diabetes Disability Epilepsy/Seizure Gastrointestinal/stomach complaints Liver and/or kidney problems Liver and or kidney problems Heart Disease (eg angina or high blood pressure)	Immune system condition Mental Health Issues Neurological (nervous system) illness Respiratory (lung) disease Rheumatology (joint) conditions Spleen problems Other - if yes: please give details below

Women Only

Are you pregnant?

Are you Breast feeding

Are you planning a pregnancy while you are away?

Medication

Are you currently taking any medication? (including prescribed, purchased or a contraceptive pill). Please give names and details

Vaccination History - Have you had any of the following? Please give dates if you know them.

Type of Immunisation	Date if known

Have you ever taken antimalarial tablets?

Name of Antimalarial Tablet	Date if Known	Any 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 https://www.ipegs.co.uk/privacy-policy/

1 2

Country	Duration in days	Ciy or Rural
		City Rural
		City Rural
		City Rural

Disease 1	Comments	Disease	Comments

Atovaquone/Proguanil Chloroquine Only Chloroquine and Proguanil Doxycycline Proguanil Only Mefloquine Influenza MMR BCG/Mantoux Yellow Fever		Meningitis ACWY Hepatitis A Hepatitis B Hepatitis A & B Hepatitis A & Typhoid Rabies Tickborne Encephalitis Japanese Encephalitis Cholera Typhoid Dip/Tet/Polio

Travel Questionnaire

Medication

Health Professional Use Only

For Reception Use Only