Pre Travel Health & Vaccination Assessment
Please complete and submit this form for each patient who will be travelling. The practice nurse will assess what immunisations you may need and whether you need malaria medication. PLEASE SUBMIT AS SOON AS POSSIBLE AND BOOK A DOUBLE APPOINTMENT WITH THE PRACTICE NURSE A WEEK AFTER SUBMITTING YOUR FORM, BUT AT LEAST TWO WEEKS BEFORE YOU TRAVEL.
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indicates required fields
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Surname:
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Forename:
Telephone Number:
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Date of Birth:
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Sex:
Male
Female
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What is your departure date:
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How long will you be away:
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List all countries you will visit:
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Will your jouney take you to the:
coast
interior
islands
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Will you be staying in:
toursit hotels
relatives' homes
local accomodation
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Are you travelling with:
family
partner
alone
group
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Are you going on:
an organised package tour
organising it yourself
backpacking
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Is your journey for:
pleasure
business
for a period of voluntary service in a remote area
Will you be:
on safari
travelling in remote locations
taking part in adventure sports
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Will you be away from medical help:
No
Yes
If yes give details:
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Are you suffering from any minor ailments:
No
Yes
If yes give details:
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Do you have any long-term medical conditions:
No
Yes
If yes give details:
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Do you have a history of epilepsy:
No
Yes
If yes give details:
Have you ever suffered with:
anxiety
depression
other psychological problems
If yes give details:
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Have you had your spleen removed:
No
Yes
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Have you ever had a bad reaction to a vaccine:
No
Yes
If yes give details:
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Do you have any allergies e.g. to eggs:
No
Yes
If yes give details:
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Are you taking any medication:
No
Yes
If yes give details:
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Have you been on antibiotics in the last 10 days:
No
Yes
FEMALES ONLY Are you:
pregnant
planning pregnancy
breast feeding
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Are you HIV positive:
No
Yes
Have you recently recieved treatment with:
radiotherapy
chemotherapy
steroids
If yes give details:
Have you previously had any of these vaccinations:
typhoid
tetanus
polio
hepatitis A or B
meningitis
rabies
yellow fever
diptheria
BCG
other vaccinations e.g. encephalitis
Please give approximate dates:
Please click on the Submit button to submit the form details.
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