Date *
GP Name
Full Name *
Date of Birth *
Gender * FemaleMale
Weight *
Address *
Phone (Home)
Phone(Work)
Phone (Other)
E-Mail *
Travel Reason HolidayWorkSportOther
Will You Be N/AScuba DivingPilot Aircraft
Departure Date *
Returning Date
Allergies * AsprinPenicillinSulpha‘sTriprimTetracycline’sCodeineOtherNo Allergies
Please specify if other
Previous Immunisations and Dates
Tetanus
Polio
Hepatitis A
Hepatitis B
Typhoid
Measles
Mumps
Rubella
Yellow Fever
Meningitis
Rabies
Japanese Encephalitis
Current Medications including self prescribed
Egg Allergy * YesNo
Important past/current medical problems (please tick)
Heart Disease
Liver Disease
Kidney Disease
Epilepsy
Skin Disease or Photosensitivity
Candida (Thrush)
Eye Disease
Gastrointestinal Disease
Blood Disease
Gout
Please Specify Other
Females Only
Pregnant
Number of Weeks
Breastfeeding
Oral Contraceptive
Oral Contraceptive name
You have read the Terms and Conditions *
Terms and Conditions:
Please note once you have sent this form that there is a charge from this point for the Nurses and Doctors time, regardless whether you are vaccinated or not. This charge covers the time taken to research and work out your vaccination requirements plus your travel consultation with the nurse.
