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Full name

Date of birth

Address

Daytime Tel

Date of departure

Destination(s), including length of say in each country

Type of holiday

For example back packing, hotel, safari, staying with relatives.

Previous vaccinations and year given

Current medical conditions

List of medications regularly taken

Are you pregnant or is it possible you might be?

Do you have any allergies?

The vaccinations and immunizations that we recommend for foreign travel and general protection are those advised by the department of health. As with every medication there is a small risk of unwanted effects, but in the case of the generally recommended vaccinations and immunizations the benefits are thought to greatly outweigh the risks. If you have any queries please ask the nurse or your doctor.

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

Patient's signature (parent if under 16)

Date

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