Travel Consultation

Medical & Health

Have you had a severe reaction (anaphylactic) to a vaccination or antimalarial before?*
YesNo

Do you faint with vaccinations?*
YesNo

Are you allergic or have had a bad reaction to anything including food eg.Eggs, medication, latex?*
YesNo

Do you suffer from or have a history of:

Please check all that apply
Anxiety / DepressionLung Disease eg AsthmaHeart DiseaseDiabetesBleeding / Clotting Disorder / DVTEpilepsy - Including Family HistoryStomach Complaints / IBDHistory of Organ TransplantHistory of AnaemiaKidney Disease / DialysisSickle CellDisabilityLiver Disease

Have you been told that you have a low immunity, eg HIV, immunocompromised, spleen removal, recent chemotherapy/radiotherapy, immunosuppressant medication in the last 6 months, solid organ/bone marrowstem cell transplant, currently or in the last month taken steroids*
YesNo

Women Only

Are you a woman, or individual of child bearing age?
YesNo

Travel Details

Reason for travel*
Please choose all that apply
HolidayRuralBusinessCruiseSafari

Activities during travel*
Please select all that apply
Visiting Relatives/FriendsTravelling AloneSports/AdventureDivingHigh Risk inc Drug Use, Tattoos, Unprotected SexAltitudeWorking with AnimalsHealthcare WorkVolunteer WorkOther

Accommodation during travel*
Please select all that apply
BackpackingHotelCamping/HostelPilgrimageRemoteOther

Country/Area 1 being visited*
Please include details of activities

Date of arrival into Country/Area 1*

Are you visiting another country/area?
YesNo

Return date from travel*

Any additional information

Vaccination History

We ask patients to bring their vaccination history to their scheduled appointment.* We will not be able to advise or vaccinate without a Vaccination History.
An up to date history can be requested from your GP Practice
Vaccination History AVAILABLE and will be brought to appointmentVaccination History NOT AVAILABLE

Please provide an email address for travel material to be forwarded efficiently

Vaccine history
Diptheria / Tetanus / PolioTyphoidHepatitis AHepatitis BMeningitisInfluenzaTick Borne EncephalitisJapanese EncephalitisYellow feverBCG/TBRabiesMMRCholeraCovidOther