Travel Vaccinations Form

Surname

Forename(s)

Date of Birth

Contact telephone number

Sex

Male

Female

Other

Prefer not to say

Date of Departure

Total Length of Trip

Please list the countries to be visited and length of stay, including any stopovers? (stopovers should include short stays in airport terminals). Please confirm if these are city or rural locations

Have you taken out travel insurance for this trip?

Yes

No

Do you plan to travel aboard in the future?

Yes

No

Work (Please specify)

Please add any additional information

Are you allergic to anything?

Yes

No

Details of your allergy

Have you had a severe reaction to a vaccine in the past?

Yes

No

Details of your reaction

Do you have any problems with your immunity?

Yes

No

Details of your immunity problem

Do you have epilepsy/seizures

Yes

No

Details of your epilepsy/seizures

Are you pregnant/planning pregnancy/breast feeding?

Yes

No

Details of your pregnancy/planning pregnancy/breast feeding

Are you having treatment for a medical condition at Beechwood Medical Practice

Yes

No

Are you having treatment for a medical condition elsewhere? e.g. hospital / private

Yes

No

If yes please give details:

Have you had vaccines given at Beechwood Medical Practice or previous GP

Yes

No

Have you had vaccines given elsewhere? (eg work/school/private clinic)

Yes

No

If yes please give details:

Any additional information you want to tell us?

You can also get free, personalised, & helpful travel & health information by registering with: www.masta-travel-health.com Please bring to your appointment if you register with this service.