Travel Vaccinations
If you think you require any travel vaccinations please print off the form below, complete and send to (or drop off at) the Practice and ring us after 3-4 working days. A Practice Nurse will look at what you require and put a message on your notes for the reception staff to book you an appropriate appointment as required.
Please note that there may be a charge for some vaccinations (please see our Charges section or ask at Reception).
Please ensure that you leave enough time for adminstering vaccinations. You are advised to contact us approximately at least 6-8 weeks before you are due to travel so that we have time to administer a course of vaccinations, if that is required.
Please complete this form, print and return to The Health Centre or fax to 0844 4996605.
(Please do not return by email as we cannot ensure the confidentiality of this form by
email).
PERSONAL DETAILS |
Name : | Date of Birth Male / Female |
Easiest contact telephone number: |
Email address: |
DATES OF TRIP |
Date of departure: |
Return date or overall length of trip: |
ITINERARY & PURPOSE OF VISIT |
Country to be visited | Length of stay | Away from medical help at destination? If so, how remote? |
1. |
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2. |
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Future travel plans |
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Please tick as appropriate 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. Accommodation | Hotel |
| Relatives / family home |
| Other | |
4. Travelling | Alone |
| With family / friend |
| In a group | |
5. Staying in area which is:- | Urban |
| Rural |
| Altitude | |
6. Planned activities | Safari |
| Adventure |
| Other | |
P Personal medical history |
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions?)
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List any current or repeat medications
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Do you have any allergies for example to eggs, antibiotics, nuts?
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Have you ever had a serious reaction to a vaccine given to you before?
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Does having an injection make you feel faint?
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Do you or any close family members have epilepsy?
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Do you have any history or mental illness including depression or anxiety?
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Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
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Women only: are you pregnancy, planning pregnancy or breast feeding?
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Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
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Please write below any further information which may be relevant.
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Vaccination history |
Have you ever had any of the following vaccinations / malaria tablets and if so when? |
Tetanus |
| Polio |
| Diphtheria |
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Typhoid |
| Hepatitis A |
| Hepatitis B |
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Meningitis |
| Yellow Fever |
| Influenza |
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Rabies |
| Jab B Encaph |
| Tick Borne |
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Other |
Malaria Tablets |
For discussion when risk assessment is performed within your appointment:
For women - I have no reason to think that I might be pregnant.
For all –
· I have received information on the risks and benefits of the vaccines recommended and have had
the opportunity to ask questions.
· I consent to the vaccines being given.
Signed :
Date :