Travel Vaccination Questionnaire

This form must be completed 8 weeks prior to appointment / travel.

Please note if any of the following applies to you

You are travelling in less than 6 weeks
You are travelling to Pakistan for more than 4 weeks
You are visiting several countries over a long period

WE ADVISE THAT YOU CONTACT A MASTA TRAVEL CLINIC FOR ALL YOUR TRAVEL VACCINE NEEDS SEE BELOW

MASTA Travel Clinic - Lloyds Pharmacy	TRAVEL VACCINATION CLINIC
24-28 Dudley Street Sedgley Dudley West Midlands DY3 1SB 0330 100 4106	Pennfields Pharmacy 248 Jeffcock Road Wolverhampton WV3 7AH 01902 341300

MASTA Travel Clinic - Lloyds Pharmacy

TRAVEL VACCINATION CLINIC

24-28 Dudley Street
Sedgley
Dudley
West Midlands
DY3 1SB

0330 100 4106

Pennfields Pharmacy
248 Jeffcock Road
Wolverhampton
WV3 7AH

01902 341300

Please note: It is the patients' responsibility to contact the surgery after 5 working days for details of any immunisations or medications that may be required.

Travel Vaccination Questionnaire

Name

Date of birth

Address

Telephone number

Destinations: Country and resort (please include any stop-overs and areas to be visited)

Date of travel

Length of stay (days)

Type

Holiday

Business

Cruise

Visiting friends /family or other

Any additional information

Medical History

Are you fit & well today

Any additional information:

Severe reaction to a vaccine before

Any additional information:

Tendency to faint with injections

Any additional information:

Any surgical operations in the past, including e.g your spleen or thymus gland removed

Any additional information:

Recent Chemotherapy, Radiotherapy, organ transplant

Any additional information:

Anaemia

Any additional information:

Bleeding / clotting disorders (including history of DVT)

Any additional information:

Heart disease (e.g. angina or high blood pressure)

Any additional information:

Diabetes

Any additional information:

Disability

Any additional information:

Epilepsy/seizures

Any additional information:

Gastrointestinal / Stomach complaints

Any additional information:

Liver or kidney problems

Any additional information:

HIV / AIDS

Any additional information:

Respiratory disease

Any additional information:

Neurological disease

Any additional information:

Rheumatology (joint) conditions

Any additional information:

Spleen problems

Any additional information:

Any other conditions?

Any additional information:

Women only

Are you pregnant?

Any additional information:

Are you breastfeeding?

Any additional information:

Are you planning a pregnancy whilst you are away?

Any additional information:

I have answered these questions correctly and to the best of my knowledge

Patient or Parent (Guardian) Name

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Key Information

Travel Vaccination Questionnaire

This form must be completed 8 weeks prior to appointment / travel.

Privacy Protection