Holiday Vaccination Form	
Name:	                                DOB:
Address:	
Male [  ]   Female [  ]                                  Contact Number:	
Dates Of Trip	
Date Of Departure:	
Return Date & overall Length Of Trip:	
Itinerary & purpose of visit	
Country to be visited       Length Of Stay	Away from Medical Help at 
1.                                     1.	Destination, if so, how remote?
2.                                     2.
3.                                     3.		
Future Travel Plans:	
Please tick as appropriate below to best describe your trip	
Type of trip:  Business [  ]   Holiday [  ]   Other [  ]	
Accommodation:  Hotel [  ]   Relatives [  ]   Other [  ]	
Area:  Urban [  ]   Rural [  ]   Other [  ]	
Activities:  Safari [  ]   Adventure [  ]   Other [  ]	
Personal medical history	
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)	
Do you have any allergies? E.g eggs, antibiotics, nuts	
Have you ever had a serious reaction to a vaccine given to you before?	
Does having an injection make you feel faint?	
Have you recently undergone radiotherapy , chemotherapy or steroid treatment?	
Women Only- Are you pregnant, planning pregnancy or breast feeding?	
Have you taken out travel insurance & if you have a medical condition, informed the insurance company about this?	
Please write below any further information which may be relevent