FOREIGN TRAVEL IMMUNISATION REQUEST

* You do not need to complete all questions, only those relevant to you. *

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PATIENT DETAILS

Patient Number (this can be found at the top of your prescription, please contact the surgery if you do not know it)

Date of Birth

Telephone No

Which country are you visiting?

Date of departure?

How long are you staying there?

days weeks

Are you stopping on the journey?

Yes No

If yes, where?

And for how long?

hours days weeks

Are you staying in a hotel or private accommodation?

Hotel Private accommodation

Will you camp or sleep rough?

Yes No

Have you previously been immunised against...
Tetanus	Yes No	Year
Polio	Yes No	Year
Typhoid	Yes No	Year
Meningitis	Yes No	Year
Cholera	Yes No	Year
Yellow Fever	Yes No	Year
Rabies	Yes No	Year
Hepatitis B	Yes No	Year
Hepatitis A	Yes No	Year
Others, e.g. Rubella
		Year
		Year

Do you have any medical problems requiring regular supervision?

Yes No
If yes, what is the problem?

Are you taking steroids?

Yes No

Are you taking any other regular medication?

Yes No

Are you pregnant?

Yes No

Have you reacted badly to any previous vaccine?

Yes No
If yes, which vaccine?

Are you allergic to any medicines?

Yes No
If yes, which?

I confirm the above answers to be correct to the best of my knowledge and request immunisation as appropriate to my trip together with advice on anti-malarial drugs.

Please tick this box to confirm that you have completed your Travel Immunisation request and click the 'Submit' button to send this request to the practice