Vaccination Questionnaire

To be completed by client prior to vaccination.

You can complete the online form below or view/download a PDF version to printout and complete HERE.

* You must complete this information.

Name*
Address
Date of Birth*
Contact Telephone

Destinations (Including all countries and stopovers)
  Destination Accommodation Length of Stay
1*
2
3
4

Clinical History  
Any current or chronic Medical conditions?
Yes

(If yes please specify)
No    
Are you currently well?
Yes

 

  
No

(If no please specify)
Are you taking any medications?
Yes

(If yes please specify)
No    
Any known allergies?
Yes

(If yes please specify)
No   NB. Allergy to eggs or chicken protein, antibiotics, or previous reaction to vaccine?
Pregnant or planning pregnancy?
Yes

(If yes please specify)
No    
Any other factors for consideration?
(e.g. immunosuppressed, on steroids, splenectomy, radiotherapy, chemotherapy or immunosuppressive treatment)
Yes

(If yes please specify)
No    
Any recent vaccinations (within the last month) e.g. TB Yellow fever, MMR?
Yes

(If yes please specify)
No    

Please note: Vaccinations can cause local reactions i.e. redness, swelling, pain etc and rarely some systemic reactions such as mild fever, malaise and joint or muscle pains can occur in the first 2-3 days. Severe reactions are very rare.

To reduce spam please type the 6 capital
letters you can see into the box.		 Logo