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Travel Vaccination Request Form

Personal Details
Names:
Age:
Date of Birth
(dd/mm/yyyy):
Sex:
Male Female
GP:
Phone Number:
Travel Itinery
Destination: Date of depature:
Length of stay: Type of trip:
Accomodation: High risk activities: Yes No
Previous / current medical history
Allergies to drugs or food? Yes No Health problems? Yes No
Currently taking any medication: Yes No Steroids: Yes No
OCP: Yes No Pregnant: Yes No
Pregnancy planned: Yes No Medical Insurance arranged: Yes No
Previous vaccination history:
Previous reactions to vaccine: Yes No Feel faint with injections: Yes No
Tetanus: Yes No Date if applicable:
Diptheria: Yes No Date if applicable:
Polio: Yes No Date if applicable:
Typhoid: Yes No Date if applicable:
Hep A 1st or booster: Yes No Date if applicable:
Hep B 1st, 2nd, 3rd, 4th Yes No Date if applicable:
Meningitis:* Yes No Date if applicable:
Yellow fever:* Yes No Date if applicable:
Malaria: Yes No Date if applicable:
Hepatitis A: Yes No Date if applicable:
Hepititis B:* Yes No Date if applicable:
Rabies:* Yes No Date if applicable:
Other: Date if applicable:
* Please note that a charge wil be made for these vaccinations / tablets
Confirmation:
Do you agree with the following statements?
I have no reason to think that I might be pregnant. Yes No
I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask question. Yes No
I consent to the vaccines being given. Yes No


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