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Travel immunisations

Netherfield Medical Centre Travel Vaccination Form

             Unfortunately

  • If you are travelling within the next FOUR WEEKS
  • Or if in the 6 WEEKS you are going on an adventure/ backpacking holiday of more than 1 month’s duration

we will be unable to offer you your injections

  • Travel Doc Tel 0800 583 3331
  • Or Walk-in Centre 8440212

You can copy this form and send to the surgery.

Personal Details

Name                                                                                                                                         Date of Birth  

Easiest contact Telephone number                                                                          

                                                                                                               Male(       ) Female (     )

 

 

Dates of Trip

Date of Departure

Return Date or overall length

 

 

 

 

Itinerary and purpose of visit

Length of Stay

Away from medical help at destination ? how far

Country to be visited

 

 

1

 

 

2

 

 

3

 

 

 

4

 

 

 

Type of trip

Business

 

Pleasure

 

Other

 

Holiday type

Package

 

Self organised

 

Backpacking

 

 

Camping

 

Cruise ship

 

Trekking

 

Accommodation

Hotel

 

Relatives/family home

 

Other

 

Travelling

Alone

 

With family /friends

 

In a group

 

Staying in area which is

Urban

 

Rural

 

Altitude

 

Planned activities

Safari

 

Adventure

 

Other

 

 

Personal Medical History                                                                                                              Yes   No

Do you have any recent past medical history of note (including diabetes, heart or lung) conditions ?

 

 

Do you have any allergies eg eggs, antibiotics nuts?

 

 

Have you had a serious reaction to a vaccine given to you before?

 

 

Does an injection make you feel faint ?

 

 

Do you or any of your close family have epilepsy ?

 

 

Do you have any history of mental illness including depression or anxiety ?

 

 

Have you recently undergone radiotherapy, chemotherapy, steroid treatment?

 

 

Women only Are you pregnant or planning a pregnancy or breast feeding?

 

 

 

 

Vaccination History

Tetanus

 

Polio

 

Diptheria

 

 

 

Typhoid

 

Hepatitis A

 

Hepatitis B

 

 

 

Meningitis

 

Yellow fever

 

Influenza

 

 

 

Rabies

 

Jap Enceph.

 

Tick Borne

 

 

 

Other

Malaria tablets

Please contact the Surgery 3 days after handing in the completed form,

when you will be advised whether or not you require any vaccinations.

If you do ,you will then need to book an appointment.



 
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