Travel vaccination form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Your detailsName *FirstLastDate of birth *Phone number *Email address *Sex *MaleFemaleTravel detailsDate of departure *Duration of trip (in days) *Details of trip *Please provide details of which country/countries will be visited, your length of stay, and how remote you will be from medical assistance.Trip descriptionPurpose of tripBusinessPleasureOther you you Activity Type of tripPackageSelf-organisedBackpackingCampingCruiseTrekkingAccommodationHotelFriends/familyOtherTravellingAloneWith friends/familyIn a groupLocationUrbanRuralAltitudeActivity typeSafariAdventureCity viewingOtherMedical historyHave you recently suffered from any infection (e.g. a heavy cold, flu, or high temperature)? *YesNoDoes having an injection cause you to feel faint? *YesNoDo you or any close family members have epilepsy? *YesNoDo you have any history of mental illness including depression or anxiety? *YesNoHave you recently undergone radiotherapy, chemotherapy or steroid treatment? *YesNoHave you taken out travel insurance? *YesNoIf you have a medical condition, have you told your insurance company about it? *YesNoAre you pregnant, planning pregnancy or breast feeding? *YesNoAre you taking an immunosuppressant medication? *YesNoList all chronic medical conditions that you have (e.g. diabetes, heart or lung conditions) *Type ‘None’ if you don’t have any.List all allergies that you have (e.g. eggs, nuts, antibiotics) *Type ‘None’ if you don’t have any.If you have had a serious reaction to a vaccine in the past, which vaccine was it? *Type ‘None’ if you don’t have any.List all of your current medications (including oral contraception) *Type ‘None’ if you don’t have any.Write below any further information that might be relevantVaccination historyHave you ever had any of the following vaccinations?TetanusPolioDiphtheriaTyphoidHepatitis AHepatitis BMeningitisYellow feverInfluenzaRabiesJapanese B encephalitisTick-borne encephalitisMalariaWhen did you have the vaccination(s) above? *ConsentThis 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 *I consent to the surgery collecting and storing my data from this form, and I acknowledge that my form will not be accepted if it is submitted with less than 6 weeks until I travelSubmit vaccination form