HOLIDAY VACCINATIONS

To help us plan appropriate precautions in good time for your journey, please make a 20 minute appointment for each member of the family at least six weeks before your departure for your pre-travel health and vaccine assessment. We will plan your vaccinations with you during your health assessment.

NAME:

ADDRESS:

TELEPHONE NO (Home/Work):

AGE

Where are you going?	Country
	City/Resort

Are there any stop overs? Yes No
If Yes, Where and When

When do you leave for your holiday/dates/seasons?

When do you return from your holiday?

What type of travelling are you doing? (Please put a cross in the box)

Business

Holiday

Touring

Camping

Caravan

Safari

Budget/Self Catering

City Break

Beach Resort

Adventure

Rural (Basic Accommodation?)

Living with Locals

Staying with Friends/Family

Will you be travelling where medical help may be non-existent; poor communications?
Yes No

Are you pregnant or planning a pregnancy? Yes No

Are you taking any medicines including the oral contraceptive pill, antibiotics etc?

Do you have any long term medical conditions or minor ailments?

Have you ever had any bad reactions to a vaccine or any allergies? Yes No

Can you remember having any of these vaccinations?

Name of Vaccine	First Dose	Second Dose	Third Dose
Polio
Tetanus
Diphtheria
Typhoid
Yellow Fever
Hepatitis A
Hepatitis B
Meningitis
Malaria Tablets

Others (Specify Below)

NOW, PLEASE PRINT THIS FORM AND HAND IT IN OR POST IT TO THE SURGERY WHEN YOU MAKE YOUR APPOINTMENT.

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