Travel questionnaire

Your medical information
Current Health Problems*
Medical History of note? Or currently undergoing chemotherapy/radiotherapy/ transplant ?*
Current Medication*
Allergies (e.g. food, latex, medication)*
Have you ever had a serious reaction to a vaccine given to you before?*
- Yes
- No

Vaccination History: Have you ever had any of the following vaccinations / malaria tablets and if so when?
Tetanus
MM slash DD slash YYYY
Polio
MM slash DD slash YYYY
Cholera
MM slash DD slash YYYY
Diphtheria
MM slash DD slash YYYY
Typhoid
MM slash DD slash YYYY
Typhoid
MM slash DD slash YYYY
Meningitis
MM slash DD slash YYYY
Yellow fever
MM slash DD slash YYYY
Influenza
MM slash DD slash YYYY
Influenza
MM slash DD slash YYYY
Rabies
MM slash DD slash YYYY
Rabies
MM slash DD slash YYYY
Hepatitis A
MM slash DD slash YYYY
Hepatitis B
MM slash DD slash YYYY
Japanese encephalitis
MM slash DD slash YYYY
Tick borne encephalitis
MM slash DD slash YYYY
BCG
MM slash DD slash YYYY
Pneumococcal
MM slash DD slash YYYY
Malaria tablets
Other vaccinations
Any additional information
PLEASE NOTE: Some Vaccines/Malaria Tablets are not covered by the NHS and will incur a charge; this will be discussed before the vaccines are given. There may be a charge for private patients.

Women only