Kingsbridge Private Hospital Pre-Travel Health Questionnaire

Please note that travel vaccinations are required 6 weeks before your date of departure. If it is less than 6 weeks before your trip please call 028 9066 7878 and we can advise you on how we can help.

If you wish to book an appointment at the Travel Clinic, please ensure you complete ALL fields in the form below. Incomplete forms may cause a delay with your appointment.

Your questionnaire has been sent. We will get back to you as soon as possible with further details.

This form requires all the "Personal Details" section, "Medical History" section and at least one full "Location to be Visited" to be filled out before submitting.

Enter Captcha.

Sorry, we couldn't send your message this time. Please try again later.

Personal Details

Name *

D.O.B *

Departure Date *

Return date

Phone Number *

Email Address *

Medical History

Medical History *

Locations to be Visited

Destination *

Length of Stay (days) *

Accommodation (hotel, tent, etc) *

Activities (safari, sports etc) *

Women Only

Are you:

Pregnant

Yes No

Possibly Pregnant

Yes No

Breast Feeding

Yes No

Conditions

Details

Psoriasis

Yes No

Epilepsy

Yes No

Cardiac problems

Yes No

Reaction to vaccines

Yes No

Spleen removed

Yes No

HIV

Yes No

Suppressed immunity

Yes No

Other (if yes, list below)

Yes No

Allergies

Details

Eggs

Yes No

Antibiotics

Yes No

Other (if yes, list below)

Yes No

Vaccine History

Vaccine

Dates Given

Details

BCG

MMR

Tetanus*

Polio*

Diptheria*

Hep A

Typhoid

Hep B

Yellow fever

Cholera

Rabies

Meningitis ACWY

Tick borne encephalitis

Influenza

Anti malaria medication (please give details)

* Usually given as one vaccine

I agree to our terms and privacy policy.

If you want to submit this form, do not enter anything in this field

Google Captcha

Kingsbridge Private Hospital,
811-815 Lisburn Road,
Belfast, BT9 7GX, Northern Ireland.
028 9066 7878