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 Name Date 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 Optional Any allergies including food, latex, medication Yes No Please give details Optional Severe reaction to a vaccine before Yes No Please give details Optional Tendency to faint with injections Yes No Please give details Optional Any surgical operations in the past, including e.g. your spleen or thymus gland removed Yes No Please give details Optional Recent chemotherapy / radiotherapy / organ transplant Yes No Please give details Optional Anaemia Yes No Please give details Optional Bleeding / clotting disorders (including history of DVT) Yes No Please give details Optional Heart disease (e.g. angina, high blood pressure) Yes No Please give details Optional Diabetes Yes No Please give details Optional Disability Yes No Please give details Optional Epilepsy / Seizures Yes No Please give details Optional Gastrointestinal (stomach) complaints Yes No Please give details Optional Liver and or kidney problems Yes No Please give details Optional HIV / AIDS Yes No Please give details Optional Immune system condition Yes No Please give details Optional Mental health issues (including anxiety, depression) Yes No Please give details Optional Neurological (nervous system) illness Yes No Please give details Optional Respiratory (lung) disease Yes No Please give details Optional Rheumataology (joint) conditions Yes No Please give details Optional Spleen problems Yes No Please give details Optional Any other conditions Yes No Please give details Optional Women 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 Optional Typhoid Optional Cholera Optional Rabies Optional Yellow Fever Optional MMR Optional Hepatitis A Optional Hepatitis B Optional Japanese encephalitis Optional BCG Optional Influenza Optional Pneumococcal Optional Meningitis Optional Tick borne encephalitis Optional Maleria Tablets Optional Other Optional Any Additional Information OptionalEmail OptionalThis field is for validation purposes and should be left unchanged.