top of page
Time for Travel Pro
Home
About
Services
Prices
Cancellation Policy
Contact
More
Use tab to navigate through the menu items.
Log In
Book Appointment
Pre-Travel Questionnaire
Pre-Travel Questionnaire
First name
(Required)
Last name
(Required)
Date of Birth
(Required)
Email
Telephone Number
(Required)
Registered Medical Practice
(Required)
What Country/Countries are you visiting?
(Required)
What is your date of departure?
(Required)
What is the duration of your stay?
(Required)
What Type of areas are you visiting?
(Required)
Urban
Rural
Both
What type of trip is it? (for example – business, holiday, religious, backpacking, charity)
(Required)
Who are you travelling with?
(Required)
Alone
With friends/ Family
In a group
Are you currently taking any medication including contraception?
(Required)
Yes
No
If yes, please list any medication sourced outside of the GP Surgery.
Do you have any current health conditions?
(Required)
Yes
No
If yes, please provide list of current health conditions:
Are you currently taking a short course of medication such as antibiotics?
(Required)
Yes
No
If yes, please provide details:
Have you ever had a reaction to a vaccine or malaria tablet in the past?
(Required)
Yes
No
If yes, please provide details including the vaccine, brand, reaction type etc:
Have you had any previous travel vaccination?
(Required)
Yes
No
If yes, please list previous vaccinations and dates if known:
Are you pregnant, planning pregnancy or breastfeeding?
(Required)
Pregnant
Planning pregnancy
Breastfeeding
None of the above
Is there anything else you feel may be relevant?
Submit
bottom of page