Travel Advice Questionnaire

https://www.nhs.uk/conditions/travel-vaccinations/

You can also access the MyGP app which can provide you with your up-to-date vaccinations you have previously had.

If you are unsure or need vaccinations please complete our Travel Advice questionnaire below.

If you are planning to travel abroad and think you may need vaccinations or antimalaria tablets please complete our travel questionnaire below (which you can fill in here and submit to us directly online) at least four to six weeks, and preferably longer, before you are due to travel.  It is not possible to provide all the necessary immunisations within the 2 weeks before your departure so please complete your form and get it back to us soonest.

Please note that we do not give Yellow Fever vaccinations and if you require these or are travelling within the next 7 days and think you may need other vaccinations please contact the School of Tropical Medicine on 0151 705 3100.

Date of Birth
Gender

Please supply information about your trip in the sections below

Date of Departure
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip
Accommodation

Please supply details of your personal medical history

Are you fit and well today?
Any allergies including food, latex, medication?
Severe reaction to a vaccine before?
Tendency to faint with injections?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Recent chemotherapy / radiotherapy / organ transplant?
Anaemia?
Bleeding / clotting disorders (including history of DVT)?
Heart disease (e.g. angina, high blood pressure)?
Diabetes?
Disability?
Epilepsy / seizures?
Gastrointestinal (stomach) complaints?
Liver and or kidney problems?
HIV / AIDS?
Immune system condition?
Mental health issues (including anxiety, depression)?
Neurological (nervous system) illness?
Rheumatology (joint) conditions?
Spleen problems?
Any other conditions?

Please supply information on any vaccines or malaria tablets taken in the past

This field is for validation purposes and should be left unchanged.