Travel vaccinations request

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Which countries do you intend to visit (including any stopovers however brief)?

Which areas in the country are you visiting?

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

List any recent or past medical history of note:

Including diabetes, heart or lung conditions

List any current or repeat medications:

List any allergies:

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

Yes

No

Don’t Know

Does having an injection make you feel faint?

Yes

No

Don’t Know

Do you or any close family members have epilepsy?

Yes

No

Don’t Know

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

Yes

No

Don’t Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Don’t Know

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

Yes

No

Don’t Know

Are you pregnant or planning pregnancy or breast feeding?

Have you ever had or are you suffering from heart disease or other chronic illness?

Please write below any further information which may be relevant:

Please state which year you had the vaccination(s):

Tetanus:

Polio:

Hepatitis A:

Hepatitis B:

Meningitis:

Yellow Fever:

Influenza:

Rabies:

Jap B Enceph:

Tick-borne Enceph (TBE):

Diptheria:

Typhoid:

Other / Malaria tablets please list here:

Remember: if you are receiving any medication, make sure that you take enough supplies to last through your overseas visit.

Signed:

Date:

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent.

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