Pmgdoctors.co.uk

Pre-Travel Questionnaire
It is essential that you visit your travel nurse well in advance of travelling abroad. They will be able to advice
you personally regarding vaccinations, malaria prevention and general health issues you should consider for
your destination.
To help us have all the right information at hand please complete the details and return to reception or you can
email the completed form to us as directed on our website.
PLEASE COMPLETE THIS FORM AT LEAST 6 WEEKS PRIOR TO TRAVEL.

General Information I will be visiting the following countries:

Please provide the following details about your trip: Region of Country: Duration of stay
Name: ……………………………………………………………. ……………………………………………………. ……………….
Date of Birth: …………………………………………………………………. ……………………………………………………. ……………….
Daytime contact number: ……………………………………………………. ……………………………………………………. ……………….
Departure Date: ………………………………………………………………. ……………………………………………………. ……………….
Return Date: …………………………………………………………………… ……………………………………………………. ……………….
Medical History I am allergic to the following things:
I am taking the following medication regularly: Eggs: ……. Antibiotics: …….
Medication: Other: …………………………………………………………………….
…………………………………………………………………………………. I have the following conditions:

…………………………………………………………………………………. Psoriasis: ……. Epilepsy: ……. HIV: …….
…………………………………………………………………………………. Cardiac problems: ……. Previous reaction to vaccine: …….
…………………………………………………………………………………. Spleen removed: ……. Pregnant/possible pregnancy: …….
…………………………………………………………………………………. I take drugs that suppress my immune system: …….
Other: …………………………………………………………………….
If you are suffering from a fever or other infection you should inform your health professional on the day you visit for
vaccinations.
Vaccination History Malaria Medication History

I have had the following vaccinations: I have previously taken the following malaria medication:

Vaccination: Dave Given: Paludrine – taken every day: …….
…………………………………….……….… ……………………. Chloroquine alone – taken once per week: …….
………………………………………….……. ……………………. Paludrine & Chloeoquine taken together: …….
………………………………………………. ……………………. Larium – taken once a week: …….
………………………………………………. ……………………. Doxycycline – taken every day: …….
………………………………………………. ……………………. Malarone – taken every day: …….
I have had these vaccinations in the past three weeks: Other/Can’t rememberthe name but I travelled to:
Yellow Fever: ……. Gamma globulin: ……. ………………………………………………………………………….
MMR: ……. BCG: ……. When I took the malaria medication:
I have no problems and took it regularly: …….
Stopped taking it before I was advised: …….
Had the following side effects: ……………………………………….
Had Malaria on return: …….

Source: http://www.pmgdoctors.co.uk/pdf_files/Pre-Travel%20Questionnaire.pdf