Travel Questionnaire | Loy Medical Centre

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4 November 2026

Travel Questionnaire Form

Please complete this form prior to booking your appointment with the Nurse for Vaccinations. We will confirm the accuracy of the dtails when you attend your appointment.

Travel Risk Assessment Form

Newsletter

Personal Information

First

Last

Date of Birth

Gender

Male

Female

Your Country of Origin

Telephone / Mobile Numbers

Please supply information about your trip in the sections below:

Date of Departure

Date of Return

Type of travel and purpose of trip

Type of Trip

Business

Pleasure

Other

Type of Holiday

Package

Self Organised

Backpacking

Camping

Cruise Ship

Trekking

Other

Accommodation

Hotel

Staying with Relative/Friends

Family Home

Other

Who are you Travelling with?

Alone

With family/friends

In a Group

Which area are you staying

Urban

Rural

Altitude

Planned Activities

Safari

Adventure

Other

Please provide any further information in the box below:

Details of Your Medical History

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)

Yes

Are you on any current or repeat medication?

Yes

Do you have any known allergies, for example to eggs, antibiotics, nuts?

Yes

Have you ever had a serious reaction to a vaccine given to you before?

Yes

Don't know

Please give details of the type of reaction you had:

Do you have a tendancy to faint with injections?

Yes

Don't know

Please give details of what made you faint, e.g. seeing the needle:

Do you or any close family members have epilepsy?

Yes

Don't know

Do you have any history or mental illness including depression or anxiety?

Yes

Don't know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

Don't know

Please give details, e.g. radiotherapy:

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Yes

Don't know

Please give details of travel insurance:

Vaccination Details

Have you ever had any of the following vaccinations / malaria tablets?

Tetanus

Polio

Diphtheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick borne encephalitis

Other

Malaria Tablets

Please provide any details if you can of all that you ticked above

Consent

I consent to the practice collecting and storing my data from this form.

Monday	9:00am to 5.00pm
Tuesday	9:00am to 5.00pm
Wednesday	9:00am to 5.00pm
Thursday	9:00am to 5.00pm
Friday	9:00am to 5.00pm
Saturday	Closed
Sunday	Closed

Travel Questionnaire Form

Personal Information

Please supply information about your trip in the sections below:

Type of travel and purpose of trip

Details of Your Medical History

Vaccination Details

Related information

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