Wells City Practice website for patients and visitors of the surgery

Wells City Practice

Priory Medical Centre, Wells, Somerset, BA5 1XJ

Tel: 01749 601333 Fax: 01749 671492 Out of Hours: Click here

Tel: 01749 601333 Fax: 01749 671492
Out of Hours: Click here

HOLIDAY TRAVEL QUESTIONNAIRE

Section 1 - Personal Details

First Names Surname Your gender

Male

Female

Date of Birth Address Postcode Email Address Daytime Telephone Number Mobile Telephone Number Your GP

Section 2 - Travel Details

Country or Countries to be Visited Type of Accomodation Method of Travel Date of Departure Date of Return Have you taken out Insurance for this trip?

Yes

Do you intend to travel abroad again in the near future?

Yes

Type of travel and purpose of trip - please select all that apply

Section 3 - Medical Information

Please provide details of your personal medical history

Are you fit and well today?

Yes

Any allergies including food, latex, medication?

Yes

Severe reaction to vaccine before?

Yes

Tendency to faint with injections?

Yes

Any surgical operations in the past? Including, e.g your spleen or thymus gland removed.

Yes

Recent Chemotherapy/radiotherapy/organ transplant?

Yes

Anaemia

Yes

Bleeding/clotting disorders (including history of DVT)

Yes

Heart disease (e.g. angina, high blood pressure)

Yes

Diabetes

Yes

Disability

Yes

Epilepsy/seizures

Yes

Gastrointestinal (stomach) complaints

Yes

Liver or kidney problems

Yes

HIV/AIDS

Yes

Immune system condition

Yes

Mental health issues (including anxiety, depression)

Yes

Neurological (nervous system) illness

Yes

Respiratory (lung) disease

Yes

Rheumatology (joint) conditions

Yes

Spleen problems

Yes

Any other conditions not mentioned above

Yes

Are you pregnant?

Yes

Are you breast feeding?

Yes

Are you planning pregnancy while away?

Yes

Are you currently taking any medication?

Please tick all that apply for any vaccines or malaria tablets taken in the past

Any Additional Information

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