Please answer as much of this form as
possible, your help here will greatly reduce the consultation time
needed for administering your vaccinations and immunisations. Items
marked with an asterisk are mandatory.
Please fill in the form below:
Personal Details:
Title:
*
Surname:
*
Forename:
*
Date of birth:
*
Address Details:
House name:
House number:
Street:
Locality:
Town:
County:
Postcode:
Contact Details:
Phone (Home):
Phone (Work):
Phone (Mobile):
Fax:
Email address:
Dates of Trip
Date of departure:
Return Date :
Length of trip :
Itinerary and Purpose of Visit
Country visited:
Length of stay:
Country visited:
Length of stay:
Country visited:
Length of stay:
Are you likely to be away from medical help at your destination?
If yes, how remote will you be?
Type of trip:
Holiday type:
Accommodation:
Travelling:
Area type:
Planned activities:
Personal Medical History
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
List any current or repeat medications
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you ever had a serious reaction to a vaccination given to you before?
Does having an injection make you feel feint?
Do you or any close family members have epilepsy?
Do you have any history or 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 travel insurance and if you have a medical condition, have you informed the insurance company about this?
Please write below any further information which may be relevant
Vaccination History :
Have you ever had any of the following vaccinations / malaria tablets and if so when?
