Full Name
*
Telephone number:
Please give details of country to be visited, length of stay, and how remote you'll be from medical help:
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 vaccine given to you before?
Yes
No
Don't Know
Does having an injection make you feel faint?
Yes
No
Don't Know
Do you or any close family members have epilepsy?
Yes
No
Don't Know
Do you have any history or mental illness including depression or anxiety?
Yes
No
Don't Know
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Yes
No
Don't Know
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Yes
No
Don't Know
Are you pregnant or planning pregnancy or breast feeding?
Please write below any further information which may be relevant
Which year did you have the Tetanus vaccination?
*
Which year did you have the Polio vaccination?
*
Which year did you have the Hepatitis A vaccination?
*
Which year did you have the Hepatitis B vaccination?
*
Which year did you have the Meningitis vaccination?
*
Which year did you have the Yellow Fever vaccination?
*
Which year did you have the Influenza vaccination?
*
Which year did you have the Rabies vaccination?
*
Which year did you have the Jap B Enceph vaccination?
*
Which year did you have the Tick Bourne vaccination?
*
Which year did you have the Diptheria vaccination?
*
Which year did you have the Typhoid vaccination?
*
If 'Other / Malaria tablets' please list here:
*
Which year did you have the other vaccination / malaria tablets?
*
