Pre-consultation: Travel Health

First name *

Last name *

Email *

Phone *

Date of birth *

Where are you travelling to? *

List each country you're visiting, even if just transiting

When do you depart? *

How long is your trip? *

Less than 1 week

1-2 weeks

2-4 weeks

1-3 months

3-6 months

More than 6 months

What is the main purpose of your trip? *

Holiday

Business

Visiting family

Volunteering

Gap year

Expedition

Working abroad

Pilgrimage (Hajj/Umrah)

Studying abroad

Other

What type of travel are you doing?

City/urban

Rural/remote

Beach resort

Backpacking

Cruise

Safari

Trekking/hiking

Camping

Where will you be staying?

Hotel/resort

Hostel

Staying with family

Camping

Unknown

Will you be at altitude above 2,500 metres?

No

Yes

Will you have exposure to freshwater (lakes, rivers, swimming)?

Schistosomiasis risk in Africa, SE Asia, and South America

No

Yes

Will you have contact with animals (farm animals, wildlife, dogs)?

Important for rabies risk assessment

No

Yes

Are you planning any adventure activities?

Diving

Caving

White water rafting

Motorbike

Off-road

None

Will you be in malaria-risk areas?

Check NaTHNaC or TravelHealthPro for your destination

No

Yes

Not sure

Do you have your vaccination records available? *

Yes - I have them

Some records

No records available

Are your routine UK vaccinations up to date?

MMR, tetanus/diphtheria/polio booster, flu (if eligible)

Yes

No

Not sure

Which travel vaccinations have you had previously?

Hepatitis A

Hepatitis B

Typhoid

Yellow Fever

Japanese Encephalitis

Rabies

Cholera

Meningitis ACWY

Tick-borne Encephalitis

None

Not sure

How many COVID-19 vaccine doses have you had?

None

1 dose

2 doses

3 doses

4+ doses

Did you experience any side effects?

Are you immunosuppressed (HIV, chemotherapy, transplant, long-term steroids)?

Affects vaccine choices - some live vaccines may be contraindicated

No

Yes

Have you had your spleen removed (splenectomy)?

Increased infection risk - additional vaccinations needed

No

Yes

Do you have an egg allergy?

Yellow fever vaccine contains egg protein

No

Yes

Do you have a gelatin allergy?

Some vaccines contain gelatin

No

Yes

Have you had a severe reaction to any vaccine?

No

Yes

Do you have epilepsy?

Mefloquine may be contraindicated

No

Yes

Do you have a history of psychiatric illness (depression, anxiety, psychosis)?

Mefloquine may be contraindicated; some vaccines affect mental health

No

Yes

Do you have kidney or liver disease?

Affects antimalarial choice and dosing

No

Yes

Are you pregnant or planning pregnancy?

Some vaccines and antimalarials are contraindicated in pregnancy

No

Not applicable

Yes

Are you breastfeeding?

Some antimalarials are excreted in breast milk

No

Yes

Do you have diabetes?

No

Yes

Do you have heart disease?

No

Yes

What medications are you currently taking?

Are you taking anticoagulants (warfarin, apixaban, rivaroxaban, dabigatran)?

Affects injection-site management for vaccines

No

Yes

Are you currently on antibiotics?

No

Yes

Are you travelling with children?

No

Yes

Are you aged 65 or over?

No

Yes

Are you travelling for medical treatment abroad?

No

Yes

Are you returning to your country of origin (visiting friends/family)?

VFR travellers often underestimate risk - childhood immunity may have waned

No

Yes

Is this an extended stay or multiple trips to the same region?

No

Yes

Have you had traveller's diarrhoea before?

No

Yes

Do you have IBS or other bowel conditions?

No

Yes

Would you like standby antibiotics for traveller's diarrhoea?

Azithromycin or ciprofloxacin can be prescribed for self-treatment

No

Yes

Do you have food allergies or special dietary requirements?

No

Yes

What do you need from your travel health consultation? *

Full travel health assessment

Specific vaccinations

Malaria prevention advice

Altitude sickness prevention

Traveller's diarrhoea advice

Fitness to fly certificate

Travel health kit

General travel advice

When is your appointment relative to your departure? *

Ideally vaccines should be given 4-6 weeks before travel to allow immunity to develop

More than 6 weeks away

4-6 weeks away

2-4 weeks away

Less than 2 weeks away

Less than 1 week away

Is there anything else you'd like us to know?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Trip Details

Where are you travelling to? -

When do you depart? -

How long is your trip? -

What is the main purpose of your trip? -

What type of travel are you doing? -

Where will you be staying? -

Risk Assessment

Will you be at altitude above 2,500 metres? -

Will you have exposure to freshwater (lakes, rivers, swimming)? -

Will you have contact with animals (farm animals, wildlife, dogs)? -

Are you planning any adventure activities? -

Will you be in malaria-risk areas? -

Vaccination History

Do you have your vaccination records available? -

Are your routine UK vaccinations up to date? -

Which travel vaccinations have you had previously? -

How many COVID-19 vaccine doses have you had? -

Malaria Prevention

Did you experience any side effects? -

Medical History

Are you immunosuppressed (HIV, chemotherapy, transplant, long-term steroids)? -

Have you had your spleen removed (splenectomy)? -

Do you have an egg allergy? -

Do you have a gelatin allergy? -

Have you had a severe reaction to any vaccine? -

Do you have epilepsy? -

Do you have a history of psychiatric illness (depression, anxiety, psychosis)? -

Do you have kidney or liver disease? -

Are you pregnant or planning pregnancy? -

Are you breastfeeding? -

Do you have diabetes? -

Do you have heart disease? -

Medications

What medications are you currently taking? -

Are you taking anticoagulants (warfarin, apixaban, rivaroxaban, dabigatran)? -

Are you currently on antibiotics? -

Special Circumstances

Are you travelling with children? -

Are you aged 65 or over? -

Are you travelling for medical treatment abroad? -

Are you returning to your country of origin (visiting friends/family)? -

Is this an extended stay or multiple trips to the same region? -

Digestive Health

Have you had traveller's diarrhoea before? -

Do you have IBS or other bowel conditions? -

Would you like standby antibiotics for traveller's diarrhoea? -

Do you have food allergies or special dietary requirements? -

Your Goals

What do you need from your travel health consultation? -

When is your appointment relative to your departure? -

Is there anything else you'd like us to know? -

Anything else for your doctor?