Travel Vaccination Form Travel Questionnaire Forms must be fully completed and returned 8 weeks prior to travel date. Forms will be reviewed each week in order of receipt, please contact Alison on 01782 793061, 2 weeks after completing the form for a travel appointment. It is the patient’s responsibility to ensure sufficient time is allowed to accommodate appointments for vaccines. Please allow longer in busier holiday periods for competition. Please note: Payments for some vaccines may be required. Full NameDate of Birth Day Month Year Gender Male Female Email Optional Contact NumberYour country of origin:Address Street Address Address Line 2 City Postcode Please supply information about your trip in the sections belowUK Departure Date Day Month Year Total duration of trip (in days)Please enter a number from 0 to 365.Country to be visitedExact location / RegionCity or RuralLength of stay Add RemoveHave you taken out travel insurance for this trip? Yes No Do you plan to travel abroad again in the future? Yes No Dont Know Type of travel and purpose of trip – Tick all that apply Holiday Business Trip Expatriate Volunteer Work Healthcare Worker Staying in Hotel Cruise Ship Trip Safari Pilgrimage Medical Tourism Backpacking Camping / Hostels Adventure Diving Visiting Friends / Family Please supply details of your personal medical historyAre you fit and well today? Yes No Please give details OptionalAny allergies including food, latex, medication Yes No Please give details OptionalSevere reaction to a vaccine before Yes No Please give details OptionalTendency to faint with injections Yes No Please give details OptionalAny surgical operations in the past, including e.g. your spleen or thymus gland removed Yes No Please give details OptionalRecent chemotherapy / radiotherapy / organ transplant Yes No Please give details OptionalAnaemia Yes No Please give details OptionalBleeding / clotting disorders (including history of DVT) Yes No Please give details OptionalHeart disease (e.g. angina, high blood pressure) Yes No Please give details OptionalDiabetes Yes No Please give details OptionalDisability Yes No Please give details OptionalEpilepsy / Seizures Yes No Please give details OptionalGastrointestinal (stomach) complaints Yes No Please give details OptionalLiver and or kidney problems Yes No Please give details OptionalHIV / AIDS Yes No Please give details OptionalImmune system condition Yes No Please give details OptionalMental health issues (including anxiety, depression) Yes No Please give details OptionalNeurological (nervous system) illness Yes No Please give details OptionalRespiratory (lung) disease Yes No Please give details OptionalRheumataology (joint) conditions Yes No Please give details OptionalSpleen problems Yes No Please give details OptionalAny other conditions Yes No Please give details OptionalWomen OnlyAre you pregnant? Yes No Are you breastfeeding? Yes No Are you planning pregnancy while away? Yes No Have you undergone FGM / been cut / circumcised? Yes No Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)? OptionalPlease supply information on any vaccines or maleria tablets taken in the past..Tetanus / polio / diphtheria OptionalTyphoid OptionalCholera OptionalRabies OptionalYellow Fever OptionalMMR OptionalHepatitis A OptionalHepatitis B OptionalJapanese encephalitis OptionalBCG OptionalInfluenza OptionalPneumococcal OptionalMeningitis OptionalTick borne encephalitis OptionalMaleria Tablets OptionalOther OptionalAny Additional Information OptionalName OptionalThis field is for validation purposes and should be left unchanged.