Pre-Travel Health Assessment

Name*
Date of Birth*

dd-mm-yy or dd/mm/yy
Tel No.
Mobile No.
(A nurse will contact you if you are up to date with all vaccines required. Please therefore provide a daytime and mobile number.)
Email*
(The nurse will email all the relevant travel information & what type & length of appointment to make. Please ensure you check your spam/junk mailbox)
Details of Trip - Countries to be visited (including stopovers)*
Departure Date*

dd-mm-yy or dd/mm/yy
Length of Stay (Days)*
Type of Accommodation (Hotel, camping, hostels etc)*
Will you be in remote areas with no medical help?*
Past Medical History
If you answer YES to any questions the Nurse will discuss this further at the time of your appointment.
Do you have any long-term medical conditions?*
Do you have a history of epilepsy?*
Have you everbeen treated for a psychological disorder? e.g. depression, anxiety, etc.*
Have you had your spleen removed?*
Are you taking any medication?*
Have you everhad a bad reaction to a vaccine?*
Do you have any allergies?*
Are you pregnant, breast feeding or planning a pregnancy?*
Are you HIV positive?*
Have you recently received radiotherapy or chemotherapy?*
Have you ever suffered from psoriasis?*
Previous Vaccinations
Email
This field is for validation purposes and should be left unchanged.