Travel

Travel Questionnaire form

Fields marked with a red asterisk are compulsory. *

Please complete a form for each member of your travelling party (including children)

Your Details

First Name(s) *

Surname *

Date of birth *

Email address *

Itinerary

Date of departure

Return date

Type of trip

Other (please state)

Accommodation

Type

Other (please state)

Further Medical Information

Have you had any antibiotic treatment in the last 8 weeks?

YesNo

Have you suffered from depression or any other psychiatric illness?

YesNo

Do you have epilepsy?

YesNo

Do you have medical problems requiring regular medication or check ups?

YesNo

Have you taken any steroids or had immunosuppressive therapy e.g. chemotherapy in the last 3 months?

YesNo

Are you allergic to any medicines?

YesNo

Have you ever reacted badly to any vaccine?

YesNo

Are you pregnant or planning a pregnancy in the next 6 months?

YesNo

Additional Information

Captcha question

How many eyes has a typical person?

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Alwoodley Medical Centre
Saxon Mount
Leeds
LS17 5DT
Tel 0113 393 0119

Surgery hours - Opening times
Monday-Tuesday 8.00am - 8.00pm
Wednesday-Friday 8.00am - 6.00pm

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Travel Questionnaire form

Your Details

Itinerary

Type of trip

Accommodation

Further Medical Information

Additional Information

Captcha question

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