Kingswood Surgery

01793 534699

Travel questionnaire

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

Kingswood 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

  • Date Format: DD slash MM slash YYYY
  • Trip dates

  • Date Format: 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.
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