Travel Assessment

Personal Details
Questionnaire
 
 
Have you ever had any of the following vaccinations / malaria tablets?
Tetanus
Polio
Diptheria
Typhoid
Hepatitis A
Hepatitis B
Other / Malaria tablets
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.