TRAVEL CLINIC INFORMATION FORM

IMPORTANT - Please read the following notes before completing this questionnaire. Your vaccinations could be delayed if the form is not fully complete.

Failure to attend a booked travel vaccination appointment or cancellation with less than 12 hours notice may incur a charge of £20.

Section 1 - Personal Details

Your gender

Your gender

Section 2 - Travel Details

Have you taken out Insurance for this trip?

Have you taken out Insurance for this trip?

Do you intend to travel abroad again in the near future?

Do you intend to travel abroad again in the near future?

Type of travel and purpose of trip - please select all that apply

Section 3 - Medical Information

Please provide details of your personal medical history

Are you fit and well today?

Are you fit and well today?

Any allergies including food, latex, medication?

Any allergies including food, latex, medication?

Severe reaction to vaccine before?

Severe reaction to vaccine before?

Tendency to faint with injections?

Tendency to faint with injections?

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

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

Recent Chemotherapy/radiotherapy/organ transplant?

Recent Chemotherapy/radiotherapy/organ transplant?

Anaemia

Anaemia

Bleeding/clotting disorders (including history of DVT)

Bleeding/clotting disorders (including history of DVT)

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

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

Diabetes

Diabetes

Disability

Disability

Epilepsy/seizures

Epilepsy/seizures

Gastrointestinal (stomach) complaints

Gastrointestinal (stomach) complaints

Liver or kidney problems

Liver or kidney problems

HIV/AIDS

HIV/AIDS

Immune system condition

Immune system condition

Mental health issues (including anxiety, depression)

Mental health issues (including anxiety, depression)

Neurological (nervous system) illness

Neurological (nervous system) illness

Respiratory (lung) disease

Respiratory (lung) disease

Rheumatology (joint) conditions

Rheumatology (joint) conditions

Spleen problems

Spleen problems

Any other conditions not mentioned above

Any other conditions not mentioned above

Are you pregnant?

Are you pregnant?

Are you breast feeding?

Are you breast feeding?

Are you planning pregnancy while away?

Are you planning pregnancy while away?

Please tick all that apply for any vaccines or malaria tablets taken in the past

Any Additional Information

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