Travelling Abroad

The Upper Eden Medical Practice are only able to provide the following NHS vaccinations: Hepatitis A, Diphtheria, Tetanus & Polio (DTP) and Typhoid.

Patients must provide the practice with at least 12 weeks’ notice before the expected date of travel.

Please note that we do not provide a private travel service at this practice and we are unable to offer travel assessments for those with complex travel vaccination requirements or any vaccinations other than those available on the NHS. Should you require further assistance, there are a number of private travel providers as well as numerous websites available for advice and information as follows:

BOOTS (Penrith/Kendal) or Dalston Pharmacy
NHS travel websites: www.fitfortravel.nhs.uk & travelhealthpro.org.uk/countries
National Travel Health Network and Centre: travelhealthpro.org.uk
Foreign and Commonwealth Office: www.gov.uk/foreign-travel-advice
Malaria for the general public: travelhealthpro.org.uk/factsheet/52/malaria

Personal details

Name

Date of birth

Are you:

Address

Telephone

Email address

Dates of trip

Date of Departure

Return date or overall length of trip

Personal medical history

Do you have any recent or past medical history of note? (Including Epilepsy, diabetes, heart or lung conditions, treatment for cancer)

List any current or repeat medications

Do you have any allergies for example to LATEX, EGGS, antibiotics or nuts?

Have you ever had a serious reaction to a vaccine given to you before?

Does having an injection make you feel faint?

Do you or any close family members have epilepsy?

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

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Women only: Are you pregnant or planning pregnancy or breast feeding?

Smoking Status:

Do you smoke

If YES, how many per day

Are you an ex –smoker

Additional Information

Please provide any further information which may be relevant

Vaccination History

Have you ever had any of the following vaccinations and if so when

Tetanus

Polio

Diphtheria

Typhoid

Hepatitis A

Influenza

Measles, Mumps and Rubella (MMR)

Covid-19

Other

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Travelling Abroad

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