Are you completing this form on behalf of
*
Yourself
Someone else (e.g. a child or dependent)
About You
Name
*
First Name(s) as appears on your passport.
Last Name(s) as appears on your passport.
Postcode
*
The one used to register with your GP.
Date of birth
*
-
Day
-
Month
Year
Your date of birth is required to verify your identity.
Sex
*
Male
Female
Other
Your Phone Number
*
The practice may use this number to contact you about your request.
Email
*
This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.
Date of Departure
-
Day
-
Month
Year
Date
Return Date
-
Day
-
Month
Year
Date
Please give details of country to be visited, length of stay, and how remote you'll be from medical help:
Type of trip
Business
Pleasure
Other
Holiday Type
Package
Self organised
Backpacking
Camping
Cruise ship
Trekking
Accommodation
Hotel
Relatives / family home
Other
Travelling
Alone
With family / friend
In a group
Staying In area which is
Urban
Rural
Altitude
Planned activities
Safari
Adventure
Other
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:
Have you ever had any of the following vaccinations / malaria tablets?
Tetanus
Polio
Diptheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Other / Malaria tablets
Which year did you have the Tick Bourne vaccination?
Which year did you have the Diptheria vaccination?
If 'Other / Malaria tablets' please list here:
Which year did you have the other vaccination / malaria tablets?
Signature
*
Date
-
Day
-
Month
Year
Date
I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent.
I confirm
Submit
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