Travel vaccination enquiry

Sex:

Male

Female

Indeterminate

Details of Travel

Date of Travel:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country to be visited, location/region, city/rural and length of stay:

Type of Travel

Type of trip:

Business

Pleasure

Other

Accommodation:

Hotel

Relatives / family home

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Other

Medical History

Do you have any allergies or a vaccine allergy?

Yes

No

Don’t Know

List any allergies:

Do you faint or feel faint with injections?

Yes

No

Don’t Know

Details:

Have you ever suffered from anxiety or depression?

Yes

No

Don’t Know

Details:

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Don’t Know

Details:

Do you have any current medical problems?

Including diabetes, heart or lung conditions

Are you pregnant or planning pregnancy or breast feeding?

List any current or repeat medications and any other medication not prescribed by your GP:

It is essential that you allow adequate time to have the immunisations for your trip. If there is not sufficient time to offer an appointment at the practice, you may be asked to go to a Private Health Clinic. We would recommend that you take out travel insurance for your trip.

I understand and agree to the above terms regarding notice of intended travel, availability of appointments and costs that I may be liable to pay.

Signed: *

Date:

Relationship of signee if not the person who is completing this form:

Please write below any additional details that you feel may be relevant:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent – it may take up to 2 working days before I receive a reply.

Tell us whether you accept cookies

Details of Travel

Type of Travel

Medical History