Princes Road Surgery

Travel Vaccinations

Personal Details
Your name: Date of birth: Sex: Male Female
Contact Number: Email address:

Dates of Trip
Date of departure: Return date or overall length of trip:

Itinerary and purpose of visit:

Country to be visited: Length of stay: Away from medical help at destination, if so, how remote:
What are your future travel plans:
Date of most recent travel: Destination(s):

Please check the boxes below to best describe your trip

1. Type of trip: Business Pleasure Other
2. Holiday type: Package Self organised Backpacking
Camping Cruise Ship Trekking
3. Accomodation: Hotel Relatives / family home Other
5. Staying in an area which is: Urban Rural Altitude

Personal Medical History

(if not applicable please leave empty)
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you ever had a serious reaction to a vaccine given to you before?
Women only:
Are you pregnant or planning pregnancy or breast feeding?
Please enter any further details which you feel may be relevant:

Vaccination History

Have you ever had any of the following vaccinations / malaria tables and if so when:
Tetanus: Polio: Diptheria:
Typhoid: Hepatitis A: Hepatitis B:
Meningitis: Yellow Fever: Influenza:
Rabies: Jap B Enceph: Tick Borne:
Other:
Malaria Tablets:

Disclaimer
For discussion when risk assesment is performed within your appointment:

I have no reason to think that I might be pregnant. I have recieved information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.
Do you accept the above statement?

please note the form will not send without this confirmation. 		Yes I accept Date:

Please note there is a charge for several of the injections, please bring cash or cheque for your appointment.


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