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Downsfield Medical Centre 315 Sheldon Heath Road, Sheldon, Birmingham, B26 2TY

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Travel Health

Travel Health

Contents

Do you need vaccinations?
Further Travel Information
Travel Vaccination Prices
Travel Assessment Form

Do you need vaccinations?

Our nurses can provide travel health advice and arrange for appropriate immunisations. Please arrange an appointment for a travel consultation at least 6-8 weeks before departure if possible. Vaccines need time to take effect and some may require a course over several weeks.

Select the region you are travelling to find out more.

Africa
Central Asia
East Asia
Australasia & Pacific
Caribbean
Central America
Europe & Russia
Middle East
North America
South America & Antarctica

Further Travel Information

The following websites will give you additional travel advice

Travel Health for information of vaccinations available on NHS
MASTA for private vaccination clinics
Gov.uk for specific country travel advice
EHIC to apply for your free European Health Insurance Card

Travel Vaccination Prices

Travel advice is covered by the NHS; however some vaccinations and prescriptions are only available privately. Payment for non-NHS services must be made at the first travel appointment.

Travel Assessment Form

We offer a full travel advice and immunisation service. If you are travelling abroad please complete and submit the travel form in plenty of time (we recommend 6-8 weeks) before your journey.

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment. Please be aware that we require at least 6 weeks notice before you travel to allow time for your vaccinations.

Name

First Last

Date of Birth

Day

Month

Year

Contact Number

Email

Enter Email Confirm Email

Gender

Female

Male

Details about your trip

Date of Departure

Day

Month

Year

Trip duration

Please give details of country to be visited, length of stay and how remote you will be from medical help

Description of your trip

Purpose of your trip

Business Optional

Pleasure Optional

Other Optional

Please specify

Type of Trip

Package Optional

Self-Organised Optional

Backpacking Optional

Camping Optional

Cruise Ship Optional

Trekking Optional

Accommodation

Hotel Optional

Friends/Family Optional

Other Optional

Please specify

Travelling

Alone Optional

With Friends/Family Optional

In a Group Optional

Location Type

Urban Optional

Rural Optional

Altitude Optional

Activity type

Safari Optional

Adventure Optional

Other Optional

Please specify

Personal Medical History

List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions) Optional

List all allergies that you have (eg. eggs, nuts, antibiotics) Optional

If you have had a serious reaction to a vaccine in the past, which vaccine was it? Optional

List all of your current medications (including oral contraception) Optional

Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?

Yes Optional

No Optional

Does having an injection cause you to feel faint?

Yes Optional

No Optional

Do you or any close family members have epilepsy?

Yes Optional

No Optional

Do you have any history of mental illness including depression or anxiety?

Yes Optional

No Optional

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes Optional

No Optional

Have you taken out travel insurance?

Yes Optional

No Optional

If you have a medical condition, have you told your insurance company about it?

Yes Optional

No Optional

Are you pregnant, planning pregnancy or breast feeding?

Yes Optional

No Optional

Write below any further information that might be relevant. Optional

Vaccination History

Have you ever had any of the following vaccinations / tablets and if so, when?

Tetanus Optional

Polio Optional

Diphtheria Optional

Typhoid Optional

Hepatitis A Optional

Hepatitis B Optional

Meningitis Optional

Yellow Fever Optional

Influenza Optional

Rabies Optional

Japanese B Enceph Optional

Tick Borne Optional

Malaria Optional

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the nhs. Please read our privacy policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form. Optional

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Downsfield Medical Centre

315 Sheldon Heath Road,
Sheldon,
Birmingham,
B26 2TY

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