Travel Vaccinations

If you have had any travel vaccinations previously, it would be extremely important to bring any details about them (e.g. your ‘yellow book’) along with you to your appointment. Please complete a questionnaire for each member of your travel party.
Once we have received your completed form, a member of our staff will contact you by phone to arrange an appointment date and time.


    Have you attended the Travel Health service here before?

    Travel Details

    Details of Your Trip

    Type of Accommodation

    Area of Accommodation

    Are you planning to work during your time abroad?

    Do you plan to travel with children?

    Do you plan to undertake any sports, during your trip?

    Does your trip include the Hajj pilgrimage to Mecca?

    Medical History

    Have you ever had any travel vaccines in the past?

    If you answered YES to the previous question. please give details here

    e.g. Yellow Fever










    Have you ever attended a GP or hospital doctor for any of the following:

    Respiratory illness including asthma

    Cardiovascular illness including raised blood pressure

    Digestive illness / Hepatitis / Jaundice

    Blood clots in the leg or lung



    Cancer / Leukaemia

    Fainting / fits / blackouts / epilepsy / convulsions

    Rheumatism / joint or back pain

    Anxiety / depression / psychiatric illness

    Ear / Eye problems

    Are you allergic to eggs?

    Have you ever had a reaction to a vaccine in the past?

    Have you ever had any other medical issues not mentioned above?

    Do you smoke?

    Are you pregnant or breast feeding?

    Trying to conceive?

    You must tell your travel doctor or nurse if you could be pregnant at the time of vaccinations or travel, as some of the vaccinations or anti-malaria tablets are not recommended in pregnancy

    Please list any medications you are currently taking or have taken in the last 3 months including steroid medication:


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