PATIENT YELLOW FEVER REQUEST FORM
DOB
Name
Age
Address
Telephone
Postcode.
Home:
Mob:
Travel Destination (s):
Please answer all of the following questions
Are you allergic to eggs?
Have you ever had a serious allergic reaction to any other thing or vaccine
Or a previous dose of yellow fever vaccine?
Are you pregnant or breast feeding?
Do you have any problems connected with your thymus gland?–
Thymemectomy,Thymoma, myasthenia gravis
(This is a rare disorder and you will have received medical attention for it)
Reduced immunity whether congenital or caused by disease or treatment
with steroids, radiotherapy, cytotoxic drugs or other including methotrexate
and other immunosuppressants?
Are you or might you be HIV positive?
Are you under 9/12 months of age or over 60 years old?
Have you had a solid organ transplant e.g. Heart/Kidney?
Have you received a bone marrow transplant within the last 6-12 months?
Have you had any illness with a high temperature on the last 3 days?
Yes
No
Do you have any medical condition?
Yes / No
If yes, please state ………………………………….
Are you on any medication?
Yes / No
If yes, please state…………………………………..
Recent “Live” Vaccines:
Have you received any vaccinations within the last month?
Yes / No
If Yes, state………………………………………………….
Date...............................
Patients Authorisation Signature and Declaration:
I have been explained the risks and benefits of having this vaccination, and agree to
proceed.
Print Name………………………………………………….. Signed ……………………….
Date…………………………………………
Practice Use Only
Date Fee paid:
Appointment Date/Time:
Date Yellow Fever Given:
Batch Number:
Clinical indications, contra-indications, comments
Nurse/GP signature