Medical Questionnaire Form - Sussex Travel Clinic

Sussex Travel Clinic Medical Questionnaire

Medical Questionnaire

Name
Email
Date of Birth
DD slash MM slash YYYY
Please fill out this questionnaire before your appointment.
Are you currently well?
- Yes
- No
Details
Are you pregnant, planning to be or breast feeding?
- Yes
- No
Details
Do you take the contraceptive pill?
- Yes
- No
Do you take any medications? Including over the counter medications or any medications you have taken in last 6 months.
- Yes
- No
Please list medications:
Have you taken steroids or had steroid injections in the last 3 months?
- Yes
- No
Details:
Are you currently taking malaria tablets or starting them soon?
- Yes
- No
Details:
Do you suffer from any allergies? Eg. Egg or others?
- Yes
- No
Details:
Have you ever had your spleen removed?
- Yes
- No
Details:
Have you or anyone in your family ever had fits, epilepsy or convulsions?
- Yes
- No
Details:
Have you or anyone in your family ever had depression or mental illness?
- Yes
- No
Details:
Have you had ultra violet light treatment recently?
- Yes
- No
Details:
Have you ever had or been treated for cancer, leukaemia, lymphoma, Hodgkin’s?
- Yes
- No
Please include details and dates of any surgery, chemotherapy or radiotherapy treatment received:
Do you have any chronic illness? Asthma, Diabetes, Others?
- Yes
- No
Details:
Have you ever had a bleeding disorder?
- Yes
- No
Details:
Have you ever been told you have anything wrong with your immune system?
- Yes
- No
Details:
Do you have known HIV infection?
- Yes
- No
Details:
Have you ever had Guillain-Barre, Myasthenia Gravis, Di- George Syndrome or a Thymus disorder?
- Yes
- No
Details:
Have you had any live vaccines in the last 4 weeks? MMR, BCG, Yellow Fever, Varicella, Shingles?
- Yes
- No
Details:
Are you having any live vaccines as above in the next 4 weeks?
- Yes
- No
Details:
Are you having or planning to have rabies vaccines?
- Yes
- No
Details:
Have you ever had glandular fever?
- Yes
- No
Details:
Have you ever felt unwell or faint after a vaccine?
- Yes
- No
Do you have comprehensive travel insurance?
- Yes
- No
Please provide details of your past medical history?

Vaccines Available

Which diseases & illnesses do we cover?

Hove Clinic

01273 749100

Worthing Clinic

01903 254774

Sussex Travel Clinic Medical Questionnaire

Medical Questionnaire

Please fill out this questionnaire before your appointment.

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Or somewhere closer to home...

Trip Planning

Vaccines Available