Occupational Vaccination Risk Assessment Form
Title
*
First Name
*
Surname
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Patient’s Address
*
Street Address
Street Address Line 2
City
County
Post Code
Email
*
example@example.com
Mobile
*
GP Practice Name
*
GP Practice Address
*
Street Address
Street Address Line 2
City
County
Post Code
Would you like your GP to be notified of this consultation
*
Yes
No
Personal Medical History
tick which of the following applies to you
Are you feeling well today?
*
Yes
No
Do you have any allergies to any medicines, latex or eggs?
*
Yes
No
If yes, please specify below:
Have you had any immunisations in the past 4 weeks?
*
Yes
No
If yes, please specify below:
Do you have any recent or past medical history of note?
Yes
No
If yes, please specify below:
Are you currently taking any medicines or repeat medicines ?
*
Yes
No
If yes, please specify below:
Have you had a serious or anaphylactic reaction to a vaccine before?
*
Yes
No
If yes, please specify below:
Do you suffer from epilepsy?
*
Yes
No
Do you have a past history of black water fever?
*
Yes
No
Do you have severe impairment of liver function?
*
Yes
No
Do you suffer from any blood disorders such as thalassemia or sickle cell anaemia?
*
Yes
No
Have you recently undergone radiotherapy, chemotherapy, steroids treatment?
*
Yes
No
If yes, please specify below:
Do you have any history of the following: anxiety, depression, heart, lung, spleen, liver, kidney, immunity, blood conditions, disorders, diabetes, immunosuppression, HIV-AIDs?
*
Yes
No
If yes, please specify below:
Vaccination History
Have you had the following vaccines before?
*
Dip Tet Polio
Typhoid Chickenpox
Hepatitis B
Meningitis
Jap B Encephalitis
Shingles
Meningitis B
MMR
Hepatitis A
Other
May you please specify the dates you had the above vaccines:
Women Only
Are you pregnant or planning a pregnancy?
Yes
No
Are you breastfeeding?
Yes
No
Submit
Should be Empty: