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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.

    Gender
    MaleFemale

    Have you attended the Travel Health service here before?
    YesNo

    Travel Details

    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:

    Message

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