Travel Vaccines Please complete the below form at least one month in advance of your travel and submit to reception for review. Personal Details Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Phone * Email * Date of Trip From * MM DD YYYY To * MM DD YYYY Return date or overall length of trip * Itinerary & Purpose of visit Countries to be visited * Length of stay * Away from medical help at destination, if so, how remote? * Please tick as appropriate to best describe your trip 1. Type of Trip * Business Pleasure Other 2. Holiday Type * Package Self-Organised Backpacking Camping Cruise Ship Trekking 3. Accommodation * Hotel Relatives / Family Home Other 4. Travelling * Alone With family / friends In a group 5. Staying in area which is * Urban Rural Altitude 6. Planned Activities * Safari Adventure Other Personal Medical History Do you have any recent or past medical history of note? (including diabetes, heart, lung conditions or epilepsy) * List any current or repeat medications * Do you have any allergies (e.g. eggs, antibiotics, nuts)? * Have you ever had a serious reaction to vaccines given to you before? * Do you have a history of 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 medical insurance and if you have a medical condition, have you informed the insurance company about this? * Please provide us with any other information which may be relevant Vaccination History Have you ever had any of the following vaccinations / malaria tablets and if so, when? * Tetanus Polio Diphtheria Typhoid Hepatitis A Hepatitis B Meningitis Yellow Fever Influenza Rabies Malaria Tablets Other If you selected 'Other', please give details of the vaccination 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 benefits of the vaccines recommended and have had the opportunity to ask questions. * I consent to the vaccines being given Thank you.We will review your form and contact you to arrange your vaccinations.
