Travel Vaccinations Questionnaire - Manchester Road East Medical Practice

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Patient Details

Name

First Name(s) Last Name

Date of Birth

Day

Month

Year

Contact Number

Country of Origin

Country

If you were not born in the UK, please select your country of origin.

I am…

Male

Female

Non-Binary

Prefer not to say

Other

Travel Details

When are you leaving?

DD slash MM slash YYYY

How long is your trip?

Where are you going?

Country

Exact Location or Region

City or Rural

Length of Stay

If you are visiting multiple countries or areas, use the ‘plus’ icon to add more.

What modes of transport will you be using?

Walking

Car / Taxi

Bus

Train

Boat (incl. Cruise Ship)

Plane

Other

Have you taken out travel insurance for this trip?

Yes

Do you plan to travel abroad again in the future?

Yes

I don’t know

What is the purpose of your trip?

Holiday

Business trip

Expatriate

Volunteer work

Healthcare worker

Staying in hotel

Cruise ship

Safari

Pilgrimage

Medical tourism

Backpacking

Camping/hostels

Adventure

Diving

Visiting friends/family

Please tick all that apply.

Medical Details (1/2)

Are you currently fit and well?

Yes

Do you have any allergies? (Food, Medication, Latex, etc.)

Yes

No known allergy

What allergies do you have?

Are you, or your partner, pregnant or planning a pregnancy?

Yes

Are you currently breast feeding?

Yes

Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?

Yes

I don’t know

Which medication(s) caused the reaction?

Do you have a tendency to 'faint' after injections?

Yes

Have you had any surgery in the past?

Yes

(e.g. open heart surgery, spleen or thymus gland removal, etc.)

What surgery did you have, and when?

Have you had any recent chemotherapy / radiotherapy / organ transplants?

Yes

What procedure did you have, and when?

Have you, or anyone in your family, undergone FGM / been cut / circumcised?

Yes

Prefer not to say

Medical Details (2/2)

Do you have any of the following medical conditions?

Anaemia

Bleeding / Clotting Disorders (including a DVT in the past)

Heart Disease (incl. Angina, High Blood Pressure)

Diabetes

Epilepsy / Seizures

Gastrointestinal / Stomach Problems

Liver / Kidney Problems

HIV / AIDS

Cancer

Immune System Condition (e.g. blood cancer)

Mental Health Difficulties (incl. Anxiety, Depression)

Neurological Illness (Nervous System)

Respiratory (Lung) Disease (incl. Asthma, COPD)

Rheumatology (Joint) Conditions (incl. Arthritis)

Spleen Problems

Please tick all that apply.

Do you have any other medical conditions, not mentioned above?

Yes

What other medical conditions do you have?

Please list any medication you are currently taking. Optional

This includes prescribed and ‘over-the-counter’ medication, and the contraceptive pill.

Have you ever had any of the following vaccines?

Malaria tablets

Tetanus/polio/diphtheria

Typhoid

Cholera

Rabies

Yellow fever

MMR

Hepatitis A

Hepatitis B

Japanese encephalitis

BCG

Influenza

Pneumococcal

COVID-19

Meningitis

Tick borne encephalitis

Please tick all that apply.

Additional Information Optional

Click the green ‘Submit’ button to complete the form.