Western Road Medical Centre

99 Western Road, Romford, Essex, RM1 3LS

It's Sunday 4:26 AM — Sorry, we're closed

Telephone: 01708 775300

Fax: 01708 737936

havccg.westernroad@nhs.net

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Contact

Contact

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Self Care A-Z

Travel Questionnaire

Personal Details
Name
First Last
Sex
- Female
- Male
Date of Birth
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Phone Number
Email
Trip Dates
Departure
Duration (Days)
Itinerary
Country Duration (Days) Availability of Medical Help
Trip Description - please tick appropriate boxes
Purpose of Trip
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- Business
- Pleasure
- Other
Type of Trip
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- Package
- Self-Organised
- Backpacking
- Camping
- Cruise Ship
- Trekking
Accommodation
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- Hotel
- Friends/Family
- Other
Travelling
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- Alone
- Friends/Family
- In a group
Location Type
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- Urban
- Rural
- Altitude
Activity Type
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- Safari
- Adventure
- Other
Personal Medical History
List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)
List all allergies that you have (eg. eggs, nuts, antibiotics)
If you have had a serious reaction to a vaccine in the past, which vaccine was it?
List all of your current medications (including oral contraception)
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- Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?
- Does having an injection cause you to feel faint?
- Do you or any close family members have epilepsy?
- Do you have any history of mental illness including depression or anxiety?
- Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
- Have you taken out travel insurance?
- If you have a medical condition, have you told your insurance company about it?
- Are you pregnant, planning pregnancy or breast feeding?
Write below any further information that might be relevant
Vaccination History
Have you ever had any of the following vaccinations / tablets and if so, when?
- Select All
- Tetanus
- Diphtheria
- Hepatitis A
- Meningitis
- Influenza
- Jap B Enceph
- Malaria Tablets
- Polio
- Typhoid
- Hepatitis B
- Yellow Fever
- Rabies
- Tick Borne
- Other
If other please state

Opening Times

Monday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Tuesday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Wednesday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Thursday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Friday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Saturday
CLOSED
Sunday
CLOSED