How do I know what vaccinations I need for travel?

Surname

First Name(s)

Address Line 1

Address Line 2

Village/Town

Postcode

Tel No

Date of Birth (dd/mm/yyyy)

Which country are you visiting?

Are visiting a town or rural area?

When do you leave? (dd/mm/yyyy)

No.

Hour(s)/Day(s)/Week(s)/Month(s)

Are you stopping anywhere on the journey? E.g. do you have to change flight?

If YES, where?

No.

Hour(s)/Day(s)/Week(s)/Month(s)

Are you staying in a hotel or private home?

Will you camp/backpack/safari?

Tetanus

When? (dd/mm/yyyy)

Polio

When?(dd/mm/yyyy)

Meningitis

When?(dd/mm/yyyy)

Yellow Fever

When?(dd/mm/yyyy)

Hepatitis B

When?(dd/mm/yyyy)

T.B.

When?(dd/mm/yyyy)

Diptheria

When?(dd/mm/yyyy)

Typhoid

When?(dd/mm/yyyy)

Cholera

When?(dd/mm/yyyy)

Rabies

When?(dd/mm/yyyy)

Hepatitis A

When?(dd/mm/yyyy)

Japanese Encephalitis

When?(dd/mm/yyyy)

Do you have any medical problem requiring medical supervision?

If YES, What is the problem?

Are you taking steroids?

Are you taking any regular medicine?

Are you pregnant or planning a pregnancy?

Have you reacted badly to any previous vaccine?

If YES, which and what was the reaction?

Do you have any allergies?

If YES, what are they?

Please tick the box to confirm the above answers to be correct to the best of your knowledge and request immunisations as appropriate to your trip together with advice on anti-malarial drugs and travel health issues.