Travel Questionnaire Form - The Linden Medical Group

About You

Date of Birth*

Phone*

NHS Number (if known) Optional

Date of departure*

How long will you be away for?*

Purpose of your trip*

Will you be travelling to remote areas?*

(more than 24hours away from medical help)

High risk activities?*

E.g. hiring a moped, bungee jumping, scuba diving, white water rafting

Who are you travelling with?*

Do you have a history of epilepsy?*

Have you ever experienced anxiety or depression that has required treatment?.*

Have you had your spleen removed?.*

Have you ever had a bad reaction to a vaccine?*

Are you pregnant or breastfeeding?*

Are you HIV positive?*

Have you recently had treatment with radio/chemotherapy or steroids?*

Are you taking any new medication?*