Travel Vaccination Consent Form

Travel Vaccination Form

Walthamstow Pharmacy
Date

DayMonthYear
Date
Patient's personal details
Title*

MrMissMsMrsDr
Name*

First NameLast Name
Telephone*
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Address (line 1)*
Address (line 2)
NHS Number
GP Name
GP Address
GP Telephone
Would you like us to send a copy of this consultation to your GP?
Dates. itinerary and purpose of trip
Date of departure*

MonthDayYear
Date
Date of return

MonthDayYear
Date

Please provide some details of your itinerary...*

	Country to be visited	Length of stay	Remote? Trek? Altitude, Medical Access?
1
2
3
4

Personal Medical History

Tick Which of the following applies to you...*

	Yes	No
Are you feeling well today?
Have you had any immunisations in the past 4 weeks?
Do you have any recent or past medical history of note?
Do you take any current or repeat medicines or are you taking halofantrine? Do you have any allergies to any medicines, latex or eggs?
Have you had a serious reaction to a vaccine, antimalarial or doxycycline before?
Do you known if you are hypersensitive to mefloquine or related compounds (e.g. quinine, quinidine) or excipients?
Do you or any of your family suffer from epilepsy? Do you have a past history of black water fever? Do you have severe impairment of liver function?
Do you suffer from any blood disorders such as thalassemia or sickle cell anaemia? Have you recently undergone radiotherapy, chemotherapy, steroids treatment?
Do you have any history of the following: anxiety, depression, heart, lung, spleen, liver, kidney, immunity, blood conditions, disorders, diabetes, immunity, HIV-AIDs?

Vaccination History

Have you had a vaccine, antimalarial or doxycycline before? (Please add dates)

	Yes	Date
Dip Tet Polio
Hepatitis B
Rabies
Shingles
MMR
Typhoid
Meningitis
Jap B Encephalitis
Meningitis B
Chickenpox
Hepatitis A
Yellow Fever
Influenza
Tick Borne Encephalitis
Malarial Tablets
Other…

Women only

Tick which of the following applies to you...

	Yes	No
Are you pregnant or planning a pregnancy?
Are you breastfeeding?

Please add any further information which may be relevant e.g. Medicines, conditions.
Should be Empty: