Perth and Scone Medical Group - Taymount Surgery, Perth and Scone Surgery, Scone
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Travel Questionnaire

Going abroad - on holiday or business? You may need travel vaccinations depending on the country or countries you intend to visit. To help us advise you on the protection you need, please complete this questionnaire and return it to us as soon as possible before making an appointment with the practice nurse for the Travel Clinic. This should be arranged at least 6-8 weeks before you travel.

Please note that all fields must be completed.

The travel questionnaire is also available as a PDF version.

Personal Details



Male Female
(dd/mm/yyyy)


Details of Trip

(dd/mm/yyyy)
days

Which countries do you intend to visit (including brief stopovers)?
This would include different regions within a country, e.g. North India or Dehli.

CountryRegion
(give name of city/coastal town)
Duration of Stay
(in days)

What is your reason for travelling?

Holiday     Work     Volunteering     Other

Where will you be staying when you are abroad?

Hotels     Cruise Ship     Camping     Other (e.g. family house)

Does your journey include:

Coastal areas     Inland areas

Are you planning travel in any difficult terrain (e.g. safaris, jungle exploring or travel in difficult terrain)?
YES NO

If you answered YES, please give specific details (e.g. camping, backpacking, type of safari):


Medical History Details

List all chronic medical conditions you have (e.g. diabetes, heart or lung conditions):


List all your current medications (including oral contraception):


Are you allergic to anything (e.g. penicillin, eggs or nuts)?
YES NO
If yes, please list:

Have you had a serious reaction to a vaccine in the past?
YES NO
If yes, which vaccine was it?

Are you pregnant, planning pregnancy or breast feeding?
YES NO

Do you or any of your close family members have epilepsy?
YES NO

Do you have any history of mental illness, including depression or anxiety?
YES NO

Are you currently suffering from any infection (e.g. flu)?
YES NO

Is there any further information that might be relevant? If so, please provide details.


Vaccination History

Have you ever had any of the following vaccinations/tablets and, if so, when?















Remember! If you are currently taking any medication make sure that you have enough supplies to last the duration of your trip.



 
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