Patient Pre-Travel Questionnaire

Please provide as detailed answers as possible. All information is treated in strictest confidence.

Personal details:

Name: Date of Birth: //

Home address: Sex: Male Female

Telephone number: Email:@sth.nhs.uk

(Work):Other:

(Home):

Travel Details

Date of departure: // Date of return: //

Destination(s): (please include all anticipated destinations)

Country / Town/Region / Urban/Rural / Accommodation / Special Considerations / Duration
e.g. Nepal / Lhasa / Rural / Camping / High Altitude / 4 days

Accomodation: Camping=C, Hotel=H. Friends/Family=F, Backpacking/Hostels=B, Other=O

Purpose of Travel / Please Tick / Activities / Please Tick
Holiday / Trekking/Camping
Business / Backpacking/
Overlanding
Religion / Package holiday
Medical elective / Cruise ship
Aid work / Climbing/High altitude
Visiting friends and/or family / Safari
Other
(please state): / Healthcare work
Sports/Diving

Patient Pre-Travel Questionnaire

(continued)

Travel Planning (please tick one):

Are you travelling: Alone , with family or friend(s) , in a group ?

Is your trip organised: by yourself , through a travel agent , through a voluntary/missionary organisation , through work , or other (please state):.

Medical History:

Do you have any past or present medical history? Yes No

If yes, please state:

.

Do you take any regular medication (including inhalers)? Yes No

If yes, please state:

Do you have any allergies to:

Medications Yes No If yes, please state:

Food Yes No If yes, please state:

Eggs Yes No If yes, please state:

OtherYes No If yes, please state:

Women only:

Are you currently, or do you have any plans to become pregnant?

Yes No

Are you breast feeding? Yes No

Date of last period dd/mm/yyyy

Do you use an oral contraceptive pill? Yes No

Patient Pre-Travel Questionnaire

(continued)

Vaccination History

Please indicate which of the following vaccinations you have previously received. Please bring any record of vaccinations to your appointment.

Vaccine / Received Previously / Data Received
DTP (Diphtheria, Tetanus, Polio) / //
TD (Tetanus, Diphtheria) / //
Tetanus Booster / //
Typhoid / //
Hepatitis A / //
Hepatitis B / //
Meningococcal Group C / //
Meningococcal Group A,C,Y,W135 / //
Pneumococcal / //
Yellow Fever / //
Influenza (‘flu’) / //
Rabies / //
BCG (for tuberculosis) / //
Other (please state): / //

Insurance (please tick):

Have you taken out travel insurance? Yes No

Does your insurance policy or visa requirements state you need a doctor’s certificate?

Yes No Don’t know

Are there any specific questions relating to you health during travel that you would like answered? (please state)

Please read and sign below the following statement:

I certify that the above answers are true to my knowledge, and that the advice and vaccination recommendations I receive will be affected by the answers I have provided.

Name: Date: //

When completed, please send this form to either: Travel Clinic, Infectious Diseases Outpatients, E Floor, Royal Hallamshire Hospital, Sheffield S10 2JF or Fax to 0114 2268875 or email to:

Please remember to bring any other documentation (e.g. vaccination records) with you to your Travel Clinic Appointment

Thank you.

PRC _ _ _ / _ _Page NumberDate of Issue: 26/09/2008

Print Ref: (if required)1 of 3Review Date: 09/2009