Travel vaccination form

Your details

Name
Date of birth
Sex

Travel details

Date of departure
Please provide details of which country/countries will be visited, your length of stay, and how remote you will be from medical assistance.

Trip description

Purpose of trip
Type of trip
Accommodation
Travelling
Location
Activity type

Medical history

Have you recently suffered from any infection (e.g. a heavy cold, flu, or high temperature)?
Does having an injection cause you to feel faint?
Do you or any close family members have epilepsy?
Do you have any history of mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance?
If you have a medical condition, have you told your insurance company about it?
Are you taking an immunosuppressant medication?
Type ‘None’ if you don’t have any.
Type ‘None’ if you don’t have any.
Type ‘None’ if you don’t have any.
Type ‘None’ if you don’t have any.

Vaccination history

Have you ever had any of the following vaccinations?

Consent

This form collects your name, date of birth, email, other personal information, and medical details. This is to confirm you are registered with the surgery, to allow the surgery team to contact you, and to update your medical records held by the surgery and our partners in the NHS. Please read our privacy policies to discover how we protect and manage your submitted data.
Acknowledgement