Wakehurst Road, Battersea, London, SW11 6BF

Email Tel: 020 7801 1460

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TRAVEL CLINIC INFORMATION FORM

Section 1 - Personal Details

First Names Surname

Your gender

Male

Female

Date of Birth Address Postcode Email Address Daytime Telephone Number Mobile Telephone Number Your GP

Section 2 - Travel Details

Country or Countries to be Visited Type of Accomodation Method of Travel Date of Departure Date of Return

Have you taken out Insurance for this trip?

Yes

Do you intend to travel abroad again in the near future?

Yes

Type of travel and purpose of trip - please select all that apply

Additional Information

Section 3 - Medical Information

Please provide details of your personal medical history

Are you fit and well today?

Yes

Any allergies including food, latex, medication?

Yes

Severe reaction to vaccine before?

Yes

Tendency to faint with injections?

Yes

Any surgical operations in the past? Including, e.g your spleen or thymus gland removed.

Yes

Recent Chemotherapy/radiotherapy/organ transplant?

Recent Chemotherapy / Radiotherapy / Organ transplant?

Yes

Anaemia

Yes

Bleeding/clotting disorders (including history of DVT)

Bleeding / Clotting disorders (including history of DVT)

Yes

Heart disease (e.g. angina, high blood pressure)

Yes

Diabetes

Yes

Disability

Yes

Epilepsy / Seizures

Yes

Gastrointestinal (stomach) complaints

Yes

Liver or kidney problems

Yes

HIV / AIDS

Yes

Immune system condition

Yes

Mental health issues (including anxiety, depression)

Yes

Neurological (nervous system) illness

Yes

Respiratory (lung) disease

Yes

Rheumatology (joint) conditions

Yes

Spleen problems

Yes

Any other conditions not mentioned above

Yes

Are you pregnant?

Yes

Are you breast feeding?

Yes

Are you planning pregnancy while away?

Yes

Are you currently taking any medication?

Medication 1

Dose

Medication 2

Dose

Medication 3

Dose

Medication 4

Dose

Medication 5

Dose

Medication 6

Dose

Please tick all that apply for any vaccines or malaria tablets taken in the past

Details of other Vaccines Any Additional Information

Confirm your details

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TRAVEL CLINIC INFORMATION FORM

Section 1 - Personal Details

Section 2 - Travel Details

Section 3 - Medical Information

Confirm your details

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