Name
Date of Birth
Country of Birth
Arrival Date into UK
Male or Female
Contact Number
Date of Travel
Date of Return
Total Duration of Travel
Destination Information - please give a detaield itinary of all countries/regions to be visited including countries you are just passing through in the correct order. Please say how long you will stay in each area
What Accomodation type will you be staying in in each region?
Are you travelling to remote areas of away from medical help? Please give details
Reason for Travel
Type of Holiday/travel
Are you travelling with
Plannned Activities
Personal Medical History
Please tick if you have ever had
Women Only
What contracption, if any, do you use?
Give Details of medical conditions ticked above or any other current of past condition which may affect your travel plans
List any medication that you are taking including over the counter medications,vitamins and herbal remedies
List the name of any maleria tablets that you have previously taken, if you cannot remember the name of the tablet it may be useful to list the country visited when taking anti-malerial medication
Vaccination History: Please give details of previous travel vaccinations and where possible the dates given
BCG
Cholera
Tetanus
Polio
Diptheria
Hepatisis A
Hepatitis B
Influenza
Japanese B Encephalitis
Mengitis ACWY
MMR
Rabies
Tick Borne Encephalitis
Typhoid
Yellow Fever
Other
Please give any further information you feel may be relevent
Remember
• Take out adequate travel insurance including any possible activities. A European Health Insurance Card (EHIC) entitles you to free or reduced rate medical care in most EU countries. You can apply for one free of charge online (www.dh.gov.uk), by phone (0845 606 2030), or by post using a form from the Post Office
• A dental check-up before you travel may prevent problems while you are away.
• Ensure you have enough of your current medication to see you through your trip. This may include contraceptives, inhalers etc.
• Pack a first aid kit (a sterile kit of emergency equipment may be a good idea if you are going somewhere remote).
• Find out about the place you are travelling, the Foreign and Commonwealth Office website www.FCO.gov.uk contains information and up to date advice on travelling abroad, including information about risks in specific countries
This leaflet has been prepared by Sanofi Pasteur MSD to give you general information on issues relating to travel Health. It is not meant as an alternative to individual advice and should be used in conjunction with advice provided by a health care professional.
By submiting this form you are electronically signing the form and agreeing that the information it contains is correct to the best of your knowledge
