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Make an appointmentComing soon

Online appointments coming soon

Until then, please call the practice to make an appointment.

030 760 1301

Mon–Fri 08:00–17:00. Urgent care outside office hours: GP out-of-hours service Utrecht, 088 130 9670

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Travel health questionnaire

Please fill in this form as completely as possible so that we can prepare your travel advice properly. One form per person. Prefer paper? Then download the PDF form and e-mail it to info@huisartsjanskerkhof.nl.

Personal details

First name*

Last name*

Initials*

Date of birth*

Gender*

Country of birth

Date of immigration

If not born in the Netherlands

Street + house number*

Postcode + town*

Phone number*

E-mail address*

Occupation

Travel details

Destination(s)*

Country/countries and regions

Departure date*

Length of trip*

Number of days / weeks

Travelling with

Reason for travel

Multiple answers possible

holidayworkrelocationvisiting family

Accommodation

Multiple answers possible

hotel / guesthousefamily / friendsguesthouse / lodge / hutapartmentcampsite / tentwith local people

High-risk activities

Multiple answers possible

staying above 2500 m altitudecontact with animalsmedical proceduressex / tattoo / piercing(water) sports

Medical history

Are you under treatment or monitoring by a doctor?

Do you have a chronic illness?

Do you take medication prescribed by a doctor?

Including the contraceptive pill

Are you allergic to anything?

Are you pregnant or trying to become pregnant?

Which vaccinations have you had in the past?

If known. Please bring your vaccination booklet to the appointment.

I declare that I have completed this form truthfully, and I agree that this information may be used to prepare my travel advice at Huisartsenpraktijk Janskerkhof.

Signature: your full name*

Your typed name counts as your signature. Filling this in for your child? Type your own name.

Download PDF

Care

General practice Wart clinic STI testing and sexual health Mental health (POH-GGZ)Gynaecologist Surgeon All services

Practice

Contact

Medisch Centrum Janskerkhof
Nobelstraat 2A, 3512 EN Utrecht

030 760 1301 info@huisartsjanskerkhof.nl Also at De Uithof →

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