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
Date Format: MM slash DD slash YYYY
Polio
Date Format: MM slash DD slash YYYY
Cholera
Date Format: MM slash DD slash YYYY
Diphtheria
Date Format: MM slash DD slash YYYY
Typhoid
Date Format: MM slash DD slash YYYY
Typhoid
Date Format: MM slash DD slash YYYY
Meningitis
Date Format: MM slash DD slash YYYY
Yellow fever
Date Format: MM slash DD slash YYYY
Influenza
Date Format: MM slash DD slash YYYY
Influenza
Date Format: MM slash DD slash YYYY
Rabies
Date Format: MM slash DD slash YYYY
Rabies
Date Format: MM slash DD slash YYYY
Hepatitis A
Date Format: MM slash DD slash YYYY
Hepatitis B
Date Format: MM slash DD slash YYYY
Japanese encephalitis
Date Format: MM slash DD slash YYYY
Tick borne encephalitis
Date Format: MM slash DD slash YYYY
BCG
Date Format: MM slash DD slash YYYY
Pneumococcal
Date Format: 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