Travel Questionnaire

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Personal Details

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

We will place this form on your record. Please then book an appointment with nurse  (only) and advise reception that you have completed this form and they can review it prior to your appointment. The form will be be reviewed in conjunction with a due travel appointment with nurse only. Please note there are limted travel vaccine clinic appointments and it will be quicker to book with other providers as per Travel Clinic (westhampsteadmedicalcentre.com).

Please double check you've entered the correct email address
May be used to identify you
Dates and Trip Details
Personal Medical History
Including diabetes, heart or lung conditions
Signed & Dated
Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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