Travel Vaccination Questionnaire - Jesmond Health Partnership

Please complete this form as accurately as you’re able. The information you provide will help us determine what vaccines you may require.

Only submit a completed form once you have finalised your trip and confirmed dates.

Travel Vaccination

First Name *

Last Name *

Date of Birth *

Phone *

Address *

Destination *

Length of trip *

Departure Date *

Type of accommodation? *

Other accommodation?

Please detail any reactions to vaccines

Please enter the date of any vaccinations you have had:

Yellow Fever

Typhoid

Polio

Tetanus

Meningitis

Hepatitis A

Hepatitis B

Cholera

Immunoglobulin

Please detail any other vaccinations you have had.

I confirm this information is correct to the best of my knowledge *

Confirm

Today’s Date *