Seascale Health Centre				

Travel Questionnaire

This questionnaire is to help us make sure you remain healthy when traveling abroad.  

Please try and leave this questionnaire at reception 4-6 weeks before you travel in order for the information to be processed and appointments with the nurse arranged. To help us give you the best advice, please give as much information as you can.  Thank you.
    
Name:     ..............................................	 Dob:   ..........................


Address: .............................................................................................


Telephone no: .......................................        Date:  ..........................
 
Countries and areas to be visited (if you are visiting several different areas, please give your itinerary)









Type of holiday eg hotel/tourist, safari, cruise, backpacking/remote areas








Departure date:   .................................         Duration of trip:........................

Current medication including 'over the counter medicines' :... ... ... ... ... ... ... ...

... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...

... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 

... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...

... ... ... ... ... ... ... ...  ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...






Known allergies:......................................................................................


Have you ever had an allergic reaction to any vaccination?  Yes (......)  No (......)


Are you pregnant?....................................................................................

Any other relevant information:






For practice use only: Vaccinations required:

1...............................  Cost £..........       2. ........................... Cost £...........  

3................................ Cost £..........       4.. ..........................  Cost £...........  

5................................ Cost £..........       6............................ Cost £............  


7................................ Cost £..........       8............................  Cost £...........


Total Cost  £..............................


Payment received:

Date paid:  ................................

Receptionist: ..............................................