Travel Vaccination Questionnaire

TRAVEL VACCINATION QUESTIONNAIRE

Name

First

Last

Phone

Email

Gender

Male

Female

Please suply information about your trip in the section below:

Date of departure

Total length of trip:

Country to be visited

Exact location or region

City or rural

Length of stay

Country to be visited

Exact location or region

City or rural

Length of stay

Country to be visited

Exact location or region

City or rural

Length of stay

Have you taken out travel insurance for this trip?

Yes

No

Do you plan to travel abroad again in the future?

Yes

No

Type of travel and purpose of trip – please tick all that apply

Checkboxes

Please supply details of your personal medical history

Are you fit and well today?

Yes

No

Details

Any allergies including food, latex, medication?

Yes

No

Details

Severe reaction to vaccine before?

Yes

No

Details

Tendency to faint with injections?

Yes

No

Details

Any surgical operations in the past, including e.g. your spleen or thymus gland removed

Yes

No

Details

Recent chemotherapy / radiotherapy / organ transplant?

Yes

No

Details

Bleeding/clotting disorders (including history of DVT)?

Yes

No

Details

Mental health issues (including anxiety, depression)?

Yes

No

Details

Women only

Are you pregnant, breast feeding or planning pregnancy in the near future?

Yes

No

Details

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)

Please supply information on any vaccines or malaria tablets taken in the past

Other vaccines

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Any additional information:

Signed

Date

I confirm that the information I have provided is accurate – I consent to the vaccines being given & have received information on the risks & benefits of the vaccines recommended.

Useful Websites – www.fitfortravel.nhs.uk www.nathnac.org

Charges

We offer the travel health service free of charge but unfortunately the NHS does not cover the cost of all the treatments you need. Therefore, for some services you may need to pay. Payments can be made by cash or cheque at the Reception Desk.

Hepatitis A Free Adult / Child

Typhoid Free Adult / Child

Hepatitis B – full course £50 per each x 3

Meningitis ACWY £50 to £80 (depending on supplier)

Malaria (private prescription if

necessary £20– Pharmacists also make a charge for a private prescription

The following vaccines are available on request and Patient is required to pay to order.

Tick Encephalitis £78 – £80 x 3 (Order on request)

Japanese Encephalitis £126 – 150 (Order on request – cost depending on supplier)

The following injections are available free of charge if required for area visited

Combined Polio/Diphtheria/Tetanus

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