Travel Vaccination Questionnaire

Travel Vaccination Questionnaire
Please suply information about your trip in the section below:

Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip – please tick all that apply

Please supply details of your personal medical history

Are you fit and well today?
Any allergies including food, latex, medication?
Severe reaction to vaccine before?
Tendency to faint with injections?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed
Recent chemotherapy / radiotherapy / organ transplant?
Bleeding/clotting disorders (including history of DVT)?
Mental health issues (including anxiety, depression)?
Women only

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


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

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 –



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