Travel Vaccine Questionnaire - The Lawson Practice

Pre-Travel Survey

Travel Health & Vaccine Pre-Screening Questionnaire

Complete one form for each traveller before a travel vaccine appointment is arranged.

Before you start
Complete this form as fully as possible. A nurse will review the information to decide what travel health advice, vaccines and malaria prevention may be required. Some travel vaccines are available on the NHS; others are private and incur a charge. You will be told about any private costs before vaccination.

1. Patient details

To be completed by the patient or parent/guardian.

Full name (required)

Date of birth (required)

NHS numberUsually 10 digits. Leave blank if unknown.

Sex at birth

Female Male Other / prefer not to say

Mobile number (required)

Email address

Home address

Postcode (required)

Parent/guardian name

Relationship to patient

Preferred contact method (required)

Interpreter required?

No Yes

Language, if yes

2. Travel itinerary

List all countries and areas you will visit, including stopovers if you will leave the airport. At least one destination is required.

Country	City / area / region	Arrival date	Departure date	Main purpose
Country 1	Area 1	Arrival date 1	Departure date 1	Purpose 1
Country 2	Area 2	Arrival date 2	Departure date 2	Purpose 2
Country 3	Area 3	Arrival date 3	Departure date 3	Purpose 3
Country 4	Area 4	Arrival date 4	Departure date 4	Purpose 4

Additional destinations or stopovers

Travel locations and environment

Regions visited — tick all that apply

Africa (Sub-Saharan) North Africa Asia (South / South-East) Central / South America Middle East Caribbean Europe (Eastern / Central) Oceania / Pacific Islands North America / Western Europe

Area types — tick all that apply

Travel dates and duration

Overall departure date

Overall return date

Dates unsure? Yes

Length of stay

Less than 4 weeks 4 to 12 weeks More than 3 months Repeated / frequent travel

3. Purpose, accommodation and activities

These details help identify additional vaccine and malaria risks.

Purpose of travel

Holiday / visiting family Work / business Volunteering / humanitarian Pilgrimage (Hajj / Umrah) Study / placement

Other purpose

Accommodation

Other accommodation

Activities and risk factors

Will you have contact with animals, wildlife, stray dogs/cats, bats or livestock?

Yes No Unsure

Will you work or volunteer in healthcare, childcare, education, community or care settings?

Yes No

Will you spend time in rural, forested, jungle or remote areas?

Yes No Unsure

Are you attending Hajj or Umrah?

Yes No

Other activities — tick all that apply

Backpacking Adventure sports Freshwater swimming Cycling / motorbike Tattoo / piercing planned Sexual contact risk Medical or dental treatment abroad

Other activities

4. Health and medical background

Answer fully so the clinician can assess vaccine suitability and safety.

Current health

Do you have any long-term medical conditions?

No Yes

Do you take any regular medication, including injections, steroids, chemotherapy, biologics or over-the-counter medicines?

No Yes

Do you have any allergies, including eggs, antibiotics, latex, gelatine or previous vaccine reactions?

No Yes

Have you had your spleen removed, or been told it does not work properly?

No Yes

Are you pregnant, breastfeeding or planning pregnancy soon?

No Yes Not applicable

Do you have a weakened immune system, HIV, cancer treatment, transplant medication or high-dose steroids?

No Yes

Details of medical conditions, medication, allergies or previous vaccine reactions

Additional safety information

Are you currently unwell, feverish or taking antibiotics?

No Yes

Have you fainted or felt very unwell after injections, blood tests or vaccines before?

No Yes

Have you previously been told not to receive a vaccine?

No Yes

Details, if yes

5. Vaccination history

Tick vaccines you have already had and add the date or year if known.

Vaccine	Had?	Date / year	Evidence available?	Comments
Tetanus	Yes	Tetanus date or year	Tetanus evidence	Tetanus comments
Diphtheria	Yes	Diphtheria date or year	Diphtheria evidence	Diphtheria comments
Polio	Yes	Polio date or year	Polio evidence	Polio comments
Hepatitis A	Yes	Hepatitis A date or year	Hepatitis A evidence	Hepatitis A comments
Hepatitis B	Yes	Hepatitis B date or year	Hepatitis B evidence	Hepatitis B comments
Typhoid	Yes	Typhoid date or year	Typhoid evidence	Typhoid comments
Rabies	Yes	Rabies date or year	Rabies evidence	Rabies comments
Meningitis ACWY	Yes	Meningitis ACWY date or year	Meningitis ACWY evidence	Meningitis ACWY comments
Yellow Fever	Yes	Yellow Fever date or year	Yellow Fever evidence	Yellow Fever comments
Japanese Encephalitis	Yes	Japanese Encephalitis date or year	Japanese Encephalitis evidence	Japanese Encephalitis comments
Tick-Borne Encephalitis	Yes	Tick-Borne Encephalitis date or year	Tick-Borne Encephalitis evidence	Tick-Borne Encephalitis comments
Other vaccine	Yes	Other vaccine date or year	Other vaccine evidence	Other vaccine comments

Vaccines not listed above, or vaccines you are unsure about

Vaccines received in the past 12 months

6. Malaria and travel health advice

The clinician will use your destination and itinerary to assess malaria prevention advice.

Will you travel to an area where malaria is present?

Yes No Unsure

Have you ever had malaria or taken malaria prevention tablets before?

No Yes

Previous malaria or prevention tablet details

Have you had side effects from malaria tablets before, or do you have kidney, liver, mental health or heart rhythm problems?

No Yes

Details, if yes

Travel health reminder
This questionnaire supports pre-screening only. You should still read the travel health advice provided by the practice and attend any booked appointment. Seek urgent medical advice if you become unwell before travel or after returning.

7. Consent and declaration

Read and tick every statement before signing electronically.

Type your full name to sign (required)

Date (required)

Relationship if signing for the patient

How we use your information
The information will be sent to The Lawson Practice for direct care and may be recorded in your GP medical record. Read the practice privacy notice. Do not use this form for urgent medical help.

Submitting this form does not book an appointment.