Travel health

Name
First Last
Daytime telephone number*
Date of birth*
Date Format: DD slash MM slash YYYY
Sex*
- Male
- Female
Address*

Your medical information
Current Health Problems*
Medical History of note? Or currently undergoing chemotherapy/radiotherapy/ transplant ?*
Current Medication*
Allergies (e.g. food, latex, medication)*
Have you ever had a serious reaction to a vaccine given to you before?*
- Yes
- No

Vaccination History: Have you ever had any of the following vaccinations / malaria tablets and if so when?
Tetanus
Date Format: MM slash DD slash YYYY
Polio
Date Format: MM slash DD slash YYYY
Cholera
Date Format: MM slash DD slash YYYY
Diphtheria
Date Format: MM slash DD slash YYYY
Typhoid
Date Format: MM slash DD slash YYYY
Typhoid
Date Format: MM slash DD slash YYYY
Meningitis
Date Format: MM slash DD slash YYYY
Yellow fever
Date Format: MM slash DD slash YYYY
Influenza
Date Format: MM slash DD slash YYYY
Influenza
Date Format: MM slash DD slash YYYY
Rabies
Date Format: MM slash DD slash YYYY
Rabies
Date Format: MM slash DD slash YYYY
Hepatitis A
Date Format: MM slash DD slash YYYY
Hepatitis B
Date Format: MM slash DD slash YYYY
Japanese encephalitis
Date Format: MM slash DD slash YYYY
Tick borne encephalitis
Date Format: MM slash DD slash YYYY
BCG
Date Format: MM slash DD slash YYYY
Pneumococcal
Date Format: MM slash DD slash YYYY
Malaria tablets
Other vaccinations
Additional information
PLEASE NOTE: Some Vaccines/Malaria Tablets are not covered by the NHS and will incur a charge; this will be discussed before the vaccines are given. There may be a charge for private patients.
Consent*
I agree to the privacy policy.
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.

Stay safe and healthy abroad

Information for patients

IMPORTANT: If you are a last minute traveller

Travel vaccinations

Travel health checklist

Travel Questionnaire

Step 1 of 5

Your medical information

Women only

Travel details

Helpful links

Further Info