In order for us to give accurate travel advice we need certain details about your planned travel- it would be helpful if you could look at this questionnaire in advance of your appointment to ensure you have the answers to the questions below. This is particularly important if you are travelling to areas of higher risk such as Africa, Asia and South America where a detailed itinery including the areas not just the countries visited with dates would be helpful- you may wish to print this out and bring it with you as you will be asked to complete this form in surgery if not.

Llwyncelyn Practice-Pre Travel Questionnaire

Travel details
Name………………………………………	Age……	Date of birth………………
Contact Address…………………………...	M/F…….	Contact no………………...
……………………………………………. ……………………………………………. Departure date…………………………….		GP………………………...

Please complete the following questionnaire as fully as possible as we will use it to help assess the advice you need for your trip abroad. Your personal details will be kept confidential and will not be passed on to any 3rd party- we may use these details to alert you to possible problems with vaccines or travel and to remind you when boosters are due.

Please list ALL the countries you intend to visit (including brief stopovers) & duration of stay

1. Purpose of travel- business □, pleasure □ family visit □, emigration □

voluntary service/aid work□ expedition□

2. Type of accommodation- Hotels ……star □, camping□, with local families□,

primitive accommodation□

3. Are you travelling with- family □, partner □, group □, alone □

4. Is this trip –an organised package□, organised by yourself□, back packing□, other□

5. Does your journey include- coastal areas□, inland areas□, Urban, □ rural travel□

6. Mode of transport to/at destination- air□, sea□, land □, type of vehicle…………………

7. Do you plan any- safaris□, jungle exploring□, travel in difficult terrain□, remote areas□

8. Do you plan any of the following activities-climbing□, diving□ caving□

other “dangerous sports” □ -please specify…………………………………………………….

9. Medical insurance arranged? y/n

Personal health details

10. Are you pregnant y/n/na, planning a pregnancy y/n/na, breastfeedingy/n/na

11. Are you allergic to egg y/n Any other allergies?…………………………………………

12. Have you ever had a severe reaction to any injection or drug? y/n -details-………………

13. Are you on any of the following?- Oral Contraceptive Pill □, Steroids□, chemotherapy□,

recent radiotherapy□ other medication□ (please list)……………………………………...

14. Do you have or have you had?- Asthma□, epilepsy/fits□, heart problems□, diabetes□,

HIV□, splenectomy□, anxiety/ depression /psychological disorders □ other medical problems

(please give details)……………………………………………………………

15. Are you well today? y/n

16. Do you have any special needs/handicaps?…………………………………………………

17. Have you had antimalarial medication in the last year?…………………………………….

18. Previous immunisations	Tetanus y/n date	diptheria, y/n date
	polio y/n date	typhoid, y/n date
	Hep A, y/n date	Hep B, y/n date
	Influenza y/n date	yellow fever y/n date
	Meningitis y/n date	Other y/n date

Llwyncelyn Practice-Pre Travel Questionnaire

Travel details