Highlands Surgery
Travel Immunisation Questionnaire
Your Details
Surname
First Name
Date of birth
Telephone
Date of Trip
Date of Departure ……………………………………Return date or length of trip……………………………….
Destination ………………………………………………………………………………………………………………
Please tick as appropriate to best describe your trip
Package
Self organised
Backpacking
Camping
Cruise Ship
Travelling
Safari
Medical History
Yes
No
Details
Do you have any allergies ?
Have you had any reactions to vaccines before ?
Do you or any close family member have epilepsy?
Are you breastfeeding, pregnant or planning to become pregnant?
Please state any relevant medical History Diabetes, Mental health,
High blood pressure etc
Vaccination History
Tetanus/Dip/Polio
Date……………
Typhoid
Date……………
Rabies
Date……………
Hepatitis A
Date……………
Hepatitis B
Date……………
Influenza
Date……………
Meningitis
Date……………
Yellow fever
Date……………
Malaria
Date……………
Jap B Encheph
Date……………
Other …………………………………….…Date……………………………………
Signed…………………………………………………………………….
date……………………………………………….
Tear
For your protection you are recommended to have the following
Recommend Consider
Surname ………………………………………
Available from
Tetanus/Diptheria/Polio
Highlands Surgery
Typhoid
Highlands Surgery
Hepatitis A
Highlands Surgery
Hepatitis B
Masta Travel Clinic
Meningitis A & C
Masta Travel Clinic
1) Patient completes top section
Meningitis ACWY
Highlands/Masta
2) The Nurse Checks with records and
ticks recommendations and
considerations.
Yellow Fever
Masta Travel Clinic
Rabies
Masta Travel Clinic
3) Give patient the completed bottom
section to bring to clinic appointment
Japanese B Enchep
Masta Travel Clinic
Cholera
Masta Travel Clinic
Malaria
Masta Travel Clinic
First name……………………………………..
Date of birth…………………………………..