Travel Questionnaire

If you require any vaccinations relating to foreign travel you will need to make an appointment with one of our practice nurses to discuss your travel arrangements. This will include which countries and areas within countries that you are visiting to determine what vaccinations are required.

Prior to your appointment, please complete the following form and submit this to us.

Your Details

Trip Details

Trip Itinerary

Availability of Medical Help

Trip Description

Purpose of Trip:
Type of Trip:
Accommodation Type:
Location Type:
Activity Type:

Personal Medical History

If you have had a serious reaction to any vaccine in the past which vaccine was it?

Are you pregnant, planning pregnancy or breast feeding?

Vaccination History

Have you ever had any of the following vaccinations / tablets and if so when?

Hepatitis A:YesNo
Hepatitis B:YesNo
Yellow Fever:YesNo
Influenza :YesNo

Please click below to submit the form to Park Lane and an appointment will be made for you with one of our practice nurses.

For an appointment or clinical advice, contact your practice