Crawley Down Health Centre

Pre-Travel Questionnaire


Going Abroad On Holiday or Business

You may need travel vaccinations depending on the country or countries you intend to visit.
As the vaccines are not immediately effective please see the Practice Nurse at least 8 weeks before you travel (12 weeks for a trip in a remote area).
If you want to discuss anything with the nurse before your appointment, please leave a contact no. and a rough outline of your query.
On completion of this form please hand it in to the receptionist and make your appointment.

Personal Details
Your name:
Address:
Telephone Number:
Date of birth

Which countries do you intend to visit (Including brief stopovers)?:

Country to be visited Duration of stay abroad Departure Date

Please check the boxes below to best describe your trip

3. Will you be staying in Hotels Private home Other
5. Will you be staying: Only in coastal areas Only in rural areas    
6. Do you plan any safaris, jungle exploration, travel in unusual terrain or staying at high altitude?

Personal Medical History

(if not applicable please leave empty)
Are you pregnant?
Trying to conceive?
Are you allergic to anything, in particular antibiotics or eggs?
Are you taking tablets or medicines prescribed by a Doctor either on a regular basis or prescribed recently? Please list:
Do you have or have you ever had any long-standing medical condition or are you having regular follow-ups by a Doctor for any medical condition? Please list:
Have you ever had an adverse reaction to any vaccine? If so, which one?
Do you have a
tendency to faint?
NB: If you have a temperature in the day of your vaccine you will be unable to have it.
It is important to let us know if you are HIV positive...

Vaccination History

Have you ever had any of the following vaccinations / malaria tables and if so when
Tetanus
Polio
Hepatitis A  1 or 2
Typhoid
Meningitis C or A & C?
Yellow Fever
Hepatitis B x3? Booster?
Rabies
Diphtheria
Encephalitis tick-borne
Encephalitis Japanese B
BCG

Disclaimer
I confirm that answers given are correct to the best of my knowledge and request Immunisation appropriate to my trip, together with advice on anti-malaria prevention.
Do you accept the above statement?
Please note the form will not send without this confirmation. 		Yes I accept Date:

 
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