Travel Vaccination Form - Abbey Medical Centre

About You

Date of Birth*

Phone*

NHS Number (if known) Optional

Date of departure*

Length of trip*

Which countries will you be visiting?*

Please give details Optional

Will you be travelling to remote areas?*

(more than 24hours away from medical help)

Will you be undertaking any high rick activities? Please provide details Optional

E.g. hiring a moped, bungee jumping, scuba diving, white water rafting

Do you have a history of epilepsy?*

Have you ever experienced anxiety or depression that has required treatment?.*

Have you had your spleen removed?.*

Have you ever had a bad reaction to a vaccine?*

Are you taking any new medication?*

Please provide details of new medication Optional

Are you pregnant or breastfeeding?*

Have you recently had treatment with radio/chemotherapy or steroids?*

Are you HIV positive?*