Travel Vaccinations Form

Please complete the following form to request immunisation appropriate to your travel plans together with advice on anti-malarial drugs.

Failure to complete the form correctly and in full may delay your vaccination programme.

Please select the practice location most relevant to this Online Form submission:

Your Details

Title

First Name(s)

Surname

Home Address

Postcode

Home Phone Number

Mobile Phone Number

Work Phone Number

Date of BirthPlease provide in the format dd/mm/yyyy

Your Travel Arrangements

What date are you leaving the UK?Please provide in the format dd/mm/yyyy

Is the trip holiday or work?

Destinations

Please give details of which countries and areas you are visiting along with the dates of your stay.

Country 1

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Country 2

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Country 3

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Will you be visiting more than three countries?

Are you stopping elsewhere en-route?

Previous Immunisations

Please state whether you have had the following immunisations, along with the date given.

Tetanus

Date given

Typhoid

Date given

Cholera

Date given

Rabies

Date given

Hepatitis A

Date given

Polio

Date given

Meningitis

Date given

Yellow Fever

Date given

Hepatitis B

Date given

Diphtheria

Date given

Please give details of any other vaccinations you have received

Further Information

Have you had any antibiotic treatment in the last 8 weeks?

Have you suffered from depression or any other psychiatric illness?Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

Do you have epilepsy?

Do you have medical problems requiring regular medication or check ups?

Please give details of regular medication and conditions

Have you taken any steroids or had immunosuppressive therapy e.g. chemotherapy in the last 3 months?

Are you allergic to any medicines?

If yes, please give details

Have you ever reacted badly to any vaccine?

If yes, please give details

Are you pregnant or planning a pregnancy in the next 6 months?

Have you taken out travel insurance for this trip?

Do you have a tendency to faint with injections?

Are you anaemic?

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

Any bleeding /clotting disorders (including history of DVT)?

Any Heart disease (e.g. angina, high blood pressure)?

Are you a diabetic patient?

Are you breast feeding?

Have you undergone Female Genital Mutilation?

Privacy Protection

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This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Gallions Reach Health Centre • Bentham Road, London, SE28 8BE.

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