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Travel Consultation Form

You must have a consultation with a doctor before we order any vaccines, and the completed Travel Consultation Form must be submitted prior to the consultation

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Type of travel and purpose of trip – please tick all that apply

Please supply details of your personal medical history

Are you fit and well today Required

If you ansswer 'Yes' to any of the below questions, please put the details into the text box below.

Any allergies including food, latex, medication Required
Severe reaction to a vaccine before Required
Tendency to faint with injections Required
Any surgical operations in the past, including eg. Your spleen or thymus gland removed Required
Recent chemotherapy/radiotherapy/organ transplant Required
Anaemia Required
Bleeding/clotting disorders (including history of DVT) Required
Heart disease (eg angina, high blood pressure) Required
Diabetes Required
Disability Required
Epilepsy/seizures Required
Gastrointestinal (stomach) complaints Required
Liver and/or kidney problems Required
HIV/AIDS Required
Mental health issues (including anxiety, depression Required
Neurological (nervous system) illness Required
Respiratory (lung) disease Required
Rheumatology (joint) conditions Required
Spleen problems Required
Any other conditions Required

Women only:

Are you pregnant
Are you breast feeding
Are you planning pregnancy while away
Have you undergone FGM/been cut/circumcised
Please supply information on any vaccines or malaria tablets taken in the past Required

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement​ to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

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