Chilwell Valley and Meadows Travel Form

Please note: you must be a registered patient at our practice in order to receive travel advice from us.

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary

To help the travel nurses to assess your needs it is important that they receive the completed travel assessment form 8 WEEKS before your departure.

BY COMPLETING THIS FORM YOU ACCEPT THAT YOUR PERSONAL DATA AS ENTERED BELOW WILL BE SECURELY STORED ON GOOGLE'S SERVERS AND WILL ONLY BE ACCESSED BY PRACTICE STAFF FOR THE PROVISION OF YOUR HEALTHCARE. IF YOU ARE NOT HAPPY WITH THIS PLEASE RETURN TO THE PRACTICE WEBSITE AND DOWNLOAD A COPY OF THE FORM TO COMPLETE BY HAND AND GIVE TO RECEPTION.

PERSONAL INFORMATION
*required
Your name: *
Your answer
Date of birth: *
Your answer
Daytime phone number:
Your answer
Preferred method of contact:
If by phone what time is preferred:
Gender:
For women only:
Are you currently pregnant or planning a pregnancy?
Are you currently breastfeeding?
TRAVEL INFORMATION
Date of departure:
Your answer
Return date:
Your answer
Please give details of the country(s) you are travelling to, including length of stay and areas to be visited:
Your answer
Type of trip:
Holiday type: (Tick all that apply)
Accommodation:
Travelling:
Staying in area which is:
MEDICAL INFORMATION
Please list any allergies, e.g. eggs, nuts or antibiotics:
Your answer
Have you ever had a serious reaction to a vaccine given to you?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
We advise that you should have comprehensive travel insurance before travelling. Have you informed your insurance company about any past medical history?
Please write any further information you feel we should be aware of:
Your answer
Have you ever had any of these vaccinations /tablets (Tick all that apply):
I confirm that I have read the Travel Health Pro website regarding the countries I am visiting:
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms