Kingswood Surgery

01793 534699

Carfax Medical Centre

01793 541655

Travel health questionnaire

To help us offer the appropriate advice, please fill out the online form before coming to see the nurse.

Travel questionnaire

Step 1 of 2

  • Fields marked with a red asterisk are compulsory. Please fill out this form. We will confirm the accuracy of the details when you attend your appointment.
  • Personal details

  • DD slash MM slash YYYY
  • Trip dates

  • DD slash MM slash YYYY
  • Itinerary

  • (i) If you will be travelling to a place where medical help is not readily on hand, estimate how long it would take to reach a doctor.
  • Trip Description

    Please tick all boxes that apply.
    *Altitude is defined as being over 3000m or 10,000ft.