Cleland Pharmacy & Travel Clinic

info@clelandpharmacy.co.uk

Travel Clinic Assessment Form

Cleland Pharmacy & Travel Clinic

Online Travel Consultation

To speed things up and to make sure we have the right vaccines in stock before you come and visit us, please complete the below online consultation form and one of our pharmacists will call you to discuss your vaccine requirements before booking you an appointment.

    Patient Details

    Date Of Birth (DD/MM/YYYY):

    Gender:
    MaleFemaleOther

    Medical History

    Please list any allergies:

    Please list your medical conditions:

    Please list all your regular medications (regular repeat medicines, over the counter, vitamins and herbal):

    Please list all vaccines you have had and when (for travel and childhood):

    Medical Risk Assessment

    Any issues with your immune system (medications, treatments, myasthenia gravis, HIV)?:

    Past or recent surgery?

    Have you ever had cancer, leukaemia, lymphoma or had organ or bone marrow transplant? YesNo

    Have you ever had any previous reactions to vaccines? YesNo

    Does having an injection make you feel faint? YesNo

    Do you or any close family member suffer from epilepsy? YesNo

    Have you or any close family member suffered from DVT (deep vein thrombosis)? YesNo

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

    Are you pregnant or breastfeeding? YesNo

    Women: Have you undergone FGM / been cut / female circumcision? YesNo

    Travel Itinerary

    Date of departure:

    Return Date:

    Please list the Countries / Area (location is known); the length of stay in each country/area/location and how far you will be from medical help in each location? Please provide as much detail as possible

    Type of Holiday & Planned Activities

    Type of trip:

    Self OrganisedTrekkingCruise ShipPackage Holiday in ResortBackpackingMedical Volunteering

    Accommodation:

    HotelRural campingHostalOther

    Area type:

    RuralUrban (town/city)

    Planned activities (Safari / Adventure / Other)? Please provide as many details as possible.

    How far will you be from medical help?

    Vaccinations

    If you already know which vaccines you require, please list them here: