Online Travel Form

College Lane Surgery, Barnsley Road, Ackworth, WF7 7HZ
Thorpe Audlin Surgery, Thorpe Audlin, WF8 3HE

Telephone: 01977 611023 · Fax: 01977 612146

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Online Travel Form

This form is alsoavailable for download in PDF format.

Personal Details
Name:
Address:
Tel No.:
Date of Birth:
Weight:
Height:
Which resorts in which countries do you intend to visit including stopovers?:
In what accomodation will you be staying?

Does your journey include:
inland areas	Yes No
coastal areas	Yes No
safaris	Yes No
jungle or difficult terrain	Yes No
trekking at high altitude	Yes No
Date of departure:
Duration of stay abroad:

Vaccination Details
Typhoid	Yes No
Typhoid Date:
Tetanus	Yes No
Tetanus Date:
Polio	Yes No
Polio Date:
Yellow Fever	Yes No
Yellow Fever Date:
Hepatitus A	Yes No
Hepatitus A Date:
Meningitus A	Yes No
Meningitus A Date:
Other	Yes No
Other Date:

Medical History
Are you pregnant or do you plan to be pregnant 6 months AFTER your trip?	Yes No
Are you breastfeeding?	Yes No
Are you on any medication?	Yes No

Have you any history of the following ?
heart disease	Yes No
epilepsy	Yes No
kidney problems	Yes No
depressive illness	Yes No
other	Yes No
other medical conditions (please state):

Confirmation
Please initial in this box to consent to treatment: