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Travel Vaccine Questionnaire

Please complete the form prior at least one month in advance of your travel and submit to reception for review.

Personal Details:

Itinerary & Purpose of visit:

Please tick as appropriate to best describe your trip:

Type of Trip
Holiday Type Required
Accommodation Required
Travelling Required
Staying in Area Required
Planned Activities Required

Personal Medical History:

Do you have any recent or past medical history of note? (including diabetes, heart, lung conditions or epilepsy)
Do you have any allergies (e.g. eggs, antibiotics, nuts)?
Have you ever had a serious reaction to vaccines given to you before?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Do you have any history of mental illness including depression or anxiety?
Women Only: Are you pregnant or planning pregnancy or breast feeding?

Vaccination History:

Have you ever had any of the following vaccinations/malaria tablets and if so when?

For discussion when risk assessment is performed within your appointment:

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement​ to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

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