Full Name *		Sex	Male Female Other
DOB *		Age *
Phone *		Email *
Address
GP Surgery		Consent to share info with GP if required	Yes No

Clinician has checked correct details*	Yes No
Consent to storage of health information	Yes No

*Good practice to check that contact details are correct and current. For travel where certificates are issued, name must match passport.

Client is able to consent *	Yes No
Client is accompanied by someone able to consent on their behalf*	Yes No N/A

*(Mother, father or other adult with parental responsibility, legal guardian or person with lasting power of attorney)

Details of person consenting on behalf of another
Name		Relationship / legal status
Address

The client is happy to go ahead with the consultation and treatment. The clinician will explain the recommended treatment, including relevant benefits, potential side effects, and appropriate measures for managing any adverse reactions. *

Yes No

Date of Departure		Length of Trip
Countries/regions to be visited
Geography (urban, rural, jungle, safari, coastal, desert, high altitude)
Purpose (adventure, aid work, business, volunteer, cruise, diving, health worker, holiday, long term, medical treatment, pilgrimage, visiting friends and family, gap year)
Type/s of accommodation (hotel, hostel, campsite)
Reason for today's appointment

Childhood vaccinations up to date?	Yes No

Use this information with the PGDs to assess suitability for the vaccine. Note that some of this information will not necessarily exclude treatment, but will provide a better understanding of the patient. It may influence advice provided during the consultation.

Is client fit and well today?	Yes No
Does the client have any allergies, particularly to eggs or chicken protein?	Yes No
Has the client ever had a reaction to any vaccination or a history of fainting?	Yes No
Is the client pregnant or breastfeeding?	Yes No
Does the client have any of the following
blood or clotting disorders	Yes No
kidney or liver problems	Yes No
heart or lung problems	Yes No
diabetes	Yes No
epilepsy or neurological condition	Yes No
mental health condition (depression, anxiety, other)	Yes No
disability or mobility problems	Yes No
Other condition requiring regular treatment from GP or specialist	Yes No

Additional questions for clients receiving yellow fever vaccine. Note that you must be a registered centre in order to administer this vaccine. See websites for NaTHNaC/TRAVAX/Public Health Scotland.

Has the client had a reaction to a previous yellow fever vaccine?	Yes No
Does the client have any illness that might affect their immune system, for example leukaemias, lymphoma, cellular immune deficiencies, chronic lymphoproliferative conditions, or have ever received a stem cell transplant?	Yes No
Does the client have cancer or have they had cancer in the past?	Yes No
Is the client taking any medicines now or within the last 12 months that affects their immune system; for example steroids, biological or non-biological immune modulating medicines, treatment following an organ transplant?	Yes No
Is the client having chemotherapy, or have they had chemotherapy within the last year?	Yes No
Has the client ever been told they may have a problem with their thymus gland, includes myasthenia gravis or a thymoma?	Yes No
Does the client have a first-degree family relative i.e. mother, father, full sister, brother or child who has had a serious adverse reaction to yellow fever vaccine?	Yes No
Is the client living with HIV?	Yes No
Has the client had an operation to remove their thymus gland for any reason including during cardiac surgery?	Yes No

Antimalarials

Accidents and personal safety	Yes No	Food/water and diarrhoea	Yes No
Blood transmitted infection	Yes No	Bite prevention	Yes No
Sun Cream	Yes No	Travel insurance	Yes No
Clinician has discussed Female Genital Mutilation (FGM) where relevant	Yes No N/A