• 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.

  • Date of Birth*
     / /

  • Medical History

  • Do you or any members of your family have a history of:*
  • Have you recently undergone:*
  • WOMEN ONLY - Are you:
  • Are you currently taking any medication?*
  • Do you have any allergies to nuts, eggs or medication?*

  • Vaccination History

  • Have you ever used malaria medication?*
  • What travel vaccines have you previously had?*

  • Travel Details

  • Date of Departure*
     / /
  • Returning to QTN*
     / /
  • Have you taken out travel insurance?
  • Will you be travelling:
  • Will you be staying in areas that are:
  • Will you be staying in a:
  • Should be Empty: