Dr I Ferguson, Dr G Cruikshank, Dr P Sides,
Dr H Cox, Dr R Brown, Dr P Richardson.
Haworth Medical Practice
Heathcliffe Mews, Haworth
BD22 8DH
Tel. 01535 642255 Fax. 01535 645380
www.haworthmedical practice
YELLOW FEVER CONSENT FORM
Check List for Contraindictions
Yes No
Have you had a severe allergic reaction to eggs or to a previous dose of yellow
fever vaccine?




Is your immune system compromised because of a disease or treatment for a
disease?
(Examples of this are: current or recent treatment (within 6months)
with chemotherapy or radiotherapy, high doses of steroids
or other drugs that affect the immune system, recent organ or
bone marrow transplant.)


Is your immune system suppressed because of HIV infection?
(Rarely, people who are HIV positive but are fit and well, are receiving highly
active anti-retroviral therapy and have a high CD4 count may be given
the vaccine).


Do you have a disorder of the thymus gland such as myasthenia gravis, thymoma,
or a history of thymus removal or radiation?


Females only – Are you pregnant?
(Under unusual circumstances, pregnant women may be vaccinated if they are
travelling to a destination at a high risk for yellow fever. Pregnant women must
carefully consider if a trip to a yellow fever country is wise, as there are diseases in
addition to yellow fever, such as malaria, that will be a threat to their health and that
of the unborn baby.)


Are you younger than 9months old?
(Rarely, children 6-8 months old may be vaccinated)
TO COMPLETE CONSENT IN SURGERY
I consent to having Yellow fever vaccine and have read all the information above.
Patient signature …………………………………….
Print Name
…………………………………….
On questioning, this patient has none of the above contraindictions, prior to vaccination for Yellow Fever.
Yellow Fever Vaccine Given – Date ___/___/___ Batch No:____________Exp.___/____/
Signature ……………………………………………
Print Name ………………………………………….
Review January 2011