Drs Jones, Borlace, Morgan & Breaks
HEALTH CENTRE/CANOLFAN IECHYD, BEAUMARIS/BIWMARES, YNYS MON LL58 8AL
Phone 01248 810818    Fax 01248 811589    E-mail Beaumaris@wales.nhs.uk

TRAVEL QUESTIONNAIRE
If you are planning on a trip abroad you may need travel vaccinations before going. This depends on the country or countries you intend to visit and the conditions in which you’ll stay. 
We can check this for you and advise what you should have.

Please allow yourself plenty of time and then:-

1.	Complete this form and return to us as soon as possible. Please provide as much information as possible.  
Please allow a minimum of 5 working days after you have handed this form in before collecting your recommendations schedule.

2.	Collect the recommendations schedule from reception-Note: the nurse will not vaccinate without this recommendations schedule.
3.	Make an appointment to see the practice nurse for any vaccinations. All vaccinations must be paid for at the time of booking –Note: the nurse will not vaccinate unless a payment has been made. NOTE: Some private vaccinations are provided by the chemist –there is a separate charge for these and this is payable to the chemist.

It is important that you collect the recommendations schedule and pay for your course BEFORE coming to see the nurse as in some cases you may need to collect vaccines from the chemist if we do not have them stocked.

Full Name
	
Departure Date	

Address

Duration of stay abroad	

Telephone Number:
	
Are you pregnant?	

Date of Birth:
	
Any recent operations?

Weight:
	
Are allergic to anything?	

Where are you travelling?
Which countries do you intend to visit, 
please be specific giving resort, region etc including any brief stopovers, cruises etc?

Please attach itinerary if possible.

COUNTRY________________________________

REGION__________________________________

RESORT__________________________________

CRUISE___________________________________

STOPOVERS_______________________________	

Will you be staying in hotels or under more primitive conditions (ie camping)
________________________________________

Does your journey include?
Coastal areas     _________
Inland areas        _________
Rivers                 _________
Do you plan any safaris, jungle exploring, travel in difficult terrain or river trips?
________________________________________	
Have you ever had any of the following vaccinations? If so, please give approximate date

Typhoid               (  ) ______________________               
Tetanus               (  ) ______________________         
Polio                    (  ) ______________________   
Yellow Fever       (  ) ______________________   
Hepatitis A          (  ) ______________________    
Cholera               (  ) ______________________ 

Any other?