BBC News - Health
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Travel Vaccinations

Personal Details
Your name: Date of birth Sex Male Female
Contact Number: Email address:

Dates of Trip
Date of departure Return date or overall length of trip

Itinerary and purpose of visit:

Country and area to be visited Length of stay Away from medical help at destination, if so, how remote
What are your future travel plans:

Please check the boxes below to best describe your trip

1. Type of trip Business Pleasure Other
2. Holiday type Package Self organised Backpacking
Camping Cruise Ship Trekking
3. Accomodation Hotel Relatives / family home Other
4. Travelling Alone With family / friend In a group
5. Staying in an area which is Urban Rural Altitude
6. Planned activities Safari Adventure Other

Personal Medical History

(if not applicable please leave empty)
Do you have any recent or past medical history or 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 vaccine given to you before?
Does having an injection make you feel faint?
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, chemotheraphy 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, informed the insurance company about this?
Please enter any further details which you feel may be relevant

Vaccination History

Have you ever had any of the following vaccinations / malaria tablets and if so when
Tetanus
Date given: 		Polio
Date given: 		Diptheria
Date given:
Typhoid
Date given: 		Hepatitis A
Date given: 		Hepatitis B
Date given:
Meningitis
Date given: 		Yellow Fever
Date given: 		Influenza
Date given:
Rabies
Date given: 		Jap B Enceph
Date given: 		Tick Borne
Date given:
Other
Malaria Tablets

Disclaimer
To the best of my knowledge all information in this form is correct.
Do you accept the above statement?

please note the form will not send without this confirmation. 		Yes I accept Date:

Please note there is a charge for several of the injections, please bring cash or cheque for your appointment.


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