Travel Form for Parsons Heath Medical Practice

What is your e-mail address?

What is your full name?

What is your phone number?

What is your date of birth?

Birth Day:

Birth Month:

Birth Year:

What is the date of your departure?

Departure Day:

Departure Month:

Departure Year:

Please choose the appropriate option from each pop up menu to describe your holiday
Will you be staying in? (Hold down the CTRL key to select more than one item.)	Will you be travelling to ? (Hold down the CTRL key to select more than one item.) Remote Areas include those with poor communication or no medical facilities

Have you ever had any of the following vaccinations? Please check all that apply:

Typhoid	Tetanus
Hepatitis A	Hepatitis B
Hepatitis A and B	Yellow Fever
Childhood Vaccinations including polio and diphtheria

Have you a history of or are you suffering from any of the following? Please check all that apply:

Depression

Epilepsy

Heart Disease

Psychiatric Illness

Other Chronic illness please specify