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Pre-Travel Questionnaire

Please complete this questionnaire if you wish to book an appointment with the Travel Clinic.
You must complete a separate form for all travellers.

Please ensure that you disclose your past medical history and current medical conditions to ensure that we can make a full risk assessment and evaluation of your needs.
(Note, if you are completing this form within 8 weeks of your departure date we may not be able to offer an appointment for your vaccinations and there will be a consultation charge.)

Name(*)

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Date of Birth(*)

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Address(*)

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Postcode(*)

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Phone number(*)

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Email(*)

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Are you registered with Bradford on Avon Health Centre?(*)

Yes No

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Are you travelling in a family group?(*)

Yes No

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What is your departure date?(*)

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How long will you be away?(*)

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Which countries are you travelling to? Please include information on areas within each country as vaccination requirements may vary.(*)

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What is the purpose of your trip?(*)

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Where will you be staying?(*)

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What will be the location? (*)

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Type of trip(*)

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Will you be doing any specific adventurous activities?(*)

Yes No

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Please specify

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Do you have any allergies?(*)

Yes No

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Please specify

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Have you ever reacted to any vaccination?(*)

Yes No

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Please specify

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Do you feel faint when having a vaccination?(*)

Yes No

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Do you or any of your family suffer with epilepsy?(*)

Yes No

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Are you currently taking any medication?(*)

Yes No

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Please specify

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Have you suffered from any infections recently?(*)

Yes No

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Please specify

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Do you have any significant past medical history?(*)

Yes No

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Please specify

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Have you recently had any chemotherapy, radiotherapy, or immuno-suppressant treatment?(*)

Yes No

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Are you currently pregnant, planning to get pregnant or breast-feeding?(*)

Yes No

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Do you give consent to receive your vaccinations?(*)

Yes No

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Do you consent for medical staff to access your medical notes?(*)

Yes No

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Have you organised travel insurance? (*)

Yes No

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Please use this space to let us know any other information that you feel would be relevant or information (*)

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Workplace Wellness is the trading name of
Bradford on Avon Occupational Health Services Ltd.
Registered in England: 9749251
VAT no. 27144823278
Registered Office: 29 Bridge Street Bradford on Avon Wiltshire BA15 1BY

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