Aviemore medical practice travel clinic

AVIEMORE MEDICAL PRACTICE TRAVEL CLINIC
Pre-Travel Health Questionaire
Before completing this form read intructions at: http://www.aviemoremedical.co.uk/travel_clinic.htm
Please circle or underline answers as required. A form to be completed for each person that will be travelling.
Where possible, please hand the completed form in at least 8 weeks before your departure. Surname.First Name. Sex M / F DOB…………………. Address . Daytime Tel No …………………………. email…………………………………………….Mode of transport: Air /Sea / overland Date of departure from home…………. To be filled in by receptionist: Date form handed in to reception…………………. Date of appt with nurse………….
1. Please list the countries to be visited with details of your destinations as below including any stopovers. (Stop overs
should include short stays in airport terminals) Please fill in as much detail as you can as this helps decide if you Name of country
The Coast
Mountains
Length of
over 3000
stay in each
2. Will you at any time be staying more than 24 hours from medical help at the destination? Yes/No.

3. Where do you intend to stay while abroad?
International Hotel / Budget Hotel / guest house / Camping / with friends or relatives or in family home / other (please give details)………………………………………………………………………………………………………. 4 What is the purpose of your travel? Holiday / Business / Other
(i) Holiday:
package / self organised / back-packing / camping / cruise / trekking / safari / visiting relatives/friends (ii) Work:
What type of work? . Does it involve close contact with people / animals ? (iii)Other:
Please give details: (e.g. Haj, student elective) ……………………………………………………………………………………… 5 Are you travelling: in a group / with family or friends /alone
6 Are you planning/anticipating doing any sporting activities? Yes/No
Please give details……………………………………………………………………………………………………………………………………… 7 Have you had any of the following and give details below plus any other medical problems not listed
Heart Problems / High Blood Pressure / Diabetes /Asthma / Breathing problems / Allergies (eggs, nuts, antibiotics etc) / disorders of the thymus gland / Splenectomy / Severe back problems / Epilepsy / Bleeding disorder / Disorders of blood clotting / Mental illness including depression and anxiety ……………………………………………………………………………………………. . .………………………………………………………………………………………………………………………………………………………………. Is there any family history of fits/epilepsy? Yes/No. Please give details……………………………………. Have you had a serious reaction to a vaccine before? Yes/No Please give details……………………………………… Does having an injection make you feel faint? Yes/No 8 In the past 3 months have you had any of the following ?
Illness / surgery / dental treatment / radiotherapy / chemotherapy /steroid treatment
9 Women only
Yes/No Are you planning to get pregnant? Yes/No 10 Do you take any tablets /medication ? Yes/No (including oral contraceptives or HRT)
11 Have you taken out Travel Insurance? Yes/No
If you have a medical condition, have you told the Insurance Agency about it? Yes/No 12 Please tick below the vaccinations that you have in the past and the dates
If you cannot remember the exact date, just put in the nearest month and year or year. Please add any other vaccination details to the list and note those you are unsure about. Vaccination D Date given
Vaccination
Vaccination D Date given
13. Have you had any of the following tablets for malaria ?
Chloroquine / proguanil / doxycycline / malarone / larium Any reaction? Yes/No Please describe ………………………………………………………………………

Source: http://www.aviemoremedical.co.uk/Travel-%20patient%20form3.pdf