Travel Vaccines

Your Name (required)

Your Email (required)

Your Date of Birth

Your Sex
---MaleFemale

Contact Number

Date of Departure

Date of Return

Length of trip

Which countries are you visiting?

Please tick as appropriate below to best describe your trip

Type of Trip
BusinessPleasureOther

Holiday Type
PackageCampingSelf organisedBackpackingCruise ShipTrekking

Accommodation
HotelRelatives / FamilyOther

Travelling
AloneWith family/friendGroup

Staying in area which is
UrbanRuralAltitude

Planned Activities
SafariAdventureOther

Personal Medical History

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)

List any current or repeat medications

Do you have any allergies for example to eggs, antibiotics, nuts?

Have you ever had a serious reaction to a vaccine given to you before?

Does having an injection make you feel faint?

Do you or any close family members have epilepsy?

Do you have any history or mental illness including depression or anxiety?

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Women only: Are you pregnant or planning pregnancy or breast feeding?

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Please write below any further information which may be relevant;

Vaccination history

Have you ever had any of the following vaccinations / malaria tablets and if so when?
TetanusPolioDiptheriaTyphoidHepatitis AHepatitis BMeningitisYellow feverInfluenzaRabiesJap B EncephTick BourneOtherMalaria Tablets

When;

For discussion when risk assessment is performed within your appointment:
I have no reason to think that I might be pregnant. I have received information on the risks and benefi ts of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

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