QMC Travel Clinic

QMC Travel Clinic

Pre-Travel Questionnaire
Please complete a form for each person requiring a travel clinic consultation
In order for us to give you the best travel advice we need as much detail from you as possible, and this consultation can take some time. We find this is not a lot of fun for children. We therefore advise that for the initial consultation, if possible, you do not bring your children with you.

If your children require travel vaccinations, we will make a specific vaccination appointment for them. This helps to ensure a more comfortable experience and limit their possible distress at having an injection. Please note, a consultation charge will still be applicable for your child.
Full Name*

First NameLast Name
Email Address*
example@example.com
Date of Birth*

DayMonthYear
Date
Medical History
Do you or any members of your family have a history of:*

Deep Vein ThrombosisEpilepsyMental illness (including depression/anxiety)None
Have you recently undergone:*

RadiotherapyChemotherapySteroid TreatmentBlood TransfusionsNone
WOMEN ONLY - Are you:

PregnantPlanning pregnancyBreastfeedingNone
Are you currently taking any medication?*

YesNo
Please list them.
Do you have any allergies to nuts, eggs or medication?*

YesNoNot Sure
Please list them.
Vaccination History
Have you had all your childhood vaccinations and in which country?
Have you ever had a serious reaction to a vaccine before?
Have you ever used malaria medication?*

YesNoNot Sure
What and when?
What travel vaccines have you previously had?*

Hep AHep BTyphoidDiptheria & TetanusPolioYellow FeverRabiesJ EMMR(x2)None
How many doses of Hep A? Dates?
How many doses of Hep B? Dates?
How many doses of Typhoid? Dates?
How many doses of Diptheria/Tetanus? Dates?
How many doses of Polio? Dates?
How many doses of Yellow Fever? Dates?
How many doses of Rabies? Dates?
How many doses of J E? Dates?
How many doses of MMR? Dates?
Travel Details
Date of Departure*

DayMonthYear
Date
Returning to QTN*

DayMonthYear
Date
Total time away*
List the following:
List the following:
List the following:
List the following:
Have you taken out travel insurance?

YesNo
Will you be travelling:

AloneWith familyIn a group
What is the purpose of your trip?
Will you be staying in areas that are:

RuralUrbanAt altitude
Will you be staying in a:

HotelHostelFamily HomeSimple accommodationOther
What activities do you plan to do while travelling?
Please provide any further information that may be relevant, including future travel plans.
Should be Empty:

QMC Travel Clinic

Please complete a form for each person requiring a travel clinic consultation

Medical History

Vaccination History

Travel Details