Travel Vaccinations

 

If you have had any travel vaccinations previously, it would be extremely important to bring any details about them (e.g. your ‘yellow book’) along with you to your appointment.¬†Please complete a questionnaire for each member of your travel party.
Once we have received your completed form, a member of our staff will contact you by phone to arrange an appointment date and time.

Your Name

Date of Birth

Gender
MaleFemale

Nationality

Occupation

Your Email

Telephone

Have you attended the Travel Health service here before?
YesNo

Travel Details

Departure Date

Date of Return to Ireland

Destinations

Details of Your Trip

Type of Accommodation
HotelCampingOther

Area of Accommodation
UrbanRuralAt Altitude

Are you planning to work during your time abroad?
YesNo

Do you plan to travel with children?
YesNo

Do you plan to undertake any sports, during your trip?
YesNo

Does your trip include the Hajj pilgrimage to Mecca?
YesNo

Medical History

Have you ever had any travel vaccines in the past?
YesNo

If you answered YES to the previous question. please give details here

Vaccine
e.g. Yellow Fever
Date
1
2
3
4
5
6
7
8

Have you ever attended a GP or hospital doctor for any of the following:

Respiratory illness including asthma
YesNo

Cardiovascular illness including raised blood pressure
YesNo

Digestive illness / Hepatitis / Jaundice
YesNo

Blood clots in the leg or lung
YesNo

Diabetes
YesNo

HIV
YesNo

Cancer / Leukaemia
YesNo

Fainting / fits / blackouts / epilepsy / convulsions
YesNo

Rheumatism / joint or back pain
YesNo

Anxiety / depression / psychiatric illness
YesNo

Ear / Eye problems
YesNo

Are you allergic to eggs?
YesNo

Have you ever had a reaction to a vaccine in the past?
YesNo

Have you ever had any other medical issues not mentioned above?
YesNo

Do you smoke?
YesNo

Are you pregnant or breast feeding?
YesNo

Trying to conceive?
YesNo

You must tell your travel doctor or nurse if you could be pregnant at the time of vaccinations or travel, as some of the vaccinations or anti-malaria tablets are not recommended in pregnancy

Please list any medications you are currently taking or have taken in the last 3 months including steroid medication:

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SURGERY HOURS
Mon – Thurs: 9am to 5:30pm
Friday: 9am to 4:30pm
by appointment only

Call us on
(051) 421 250

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