Travel Questionnaire

Please complete our questionnaire if you're going abroad - we can advise you of any vaccinations or other protection you require.

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.

You can also download the travel questionnaire and drop it in to one of the surgeries.

Your details


Details of your trip

Which countries do you intend to visit (including brief stopovers)? Include different regions within a country e.g. North India or Dehli, and tell us how many days you will be there. Complete as many lines as you need.

What is your reason for travelling?:

Where will you be staying when you are abroad?:

Does your journey include:

Are you planning travel in any difficult terrain (e.g. safaris, jungle exploring or travel in difficult terrain)?:


Medical history

Are you allergic to anything (e.g. penicillin, eggs or nuts)?

Have you had a serious reaction to a vaccine in the past?

Are you pregnant, planning pregnancy or breast feeding?

Do you or any of your close family members have epilepsy?

Do you have any history of mental illness, including depression or anxiety?

Are you currently suffering from any infection (e.g. flu)?

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


Vaccination history

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

Tetanus:
Polio:
Typhoid:
Diphtheria:
Hep A:
Hep B:
Meningitis:
Yellow Fever:
Influenza:
Rabies:
Tick Borne Encephalitis:
Jap B Encephalitis:
Malaria Tablets:
Other:

Anything else?

Travel Health Information

The 'fitfortravel' website provided by NHS (Scotland) includes details of destinations and vaccinations required, or NHS Inform provide advice on travel health and vaccinations.

You can also phone NHS Inform on 0800 22 44 88 or use the webchat option on the NHS Inform website.

NHS Inform