Personal Medical History(if not applicable please leave empty) |
| Do you have any recent or past medical history or note? (including diabetes, heart or lung conditions) |
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| List any current or repeat medications |
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| Do you have any allergies for example to eggs, antibiotics, nuts? |
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| Have you ever had a serious reaction to a vaccine given to you before? |
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| Does having an injection make you feel faint? |
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| Do you or any close family members have epilepsy? |
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| Do you have any history or mental illness including depression or anxiety? |
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| Have you recently undergone radiotherapy, chemotheraphy or steroid treatment? |
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Women only:
Are you pregnant or planning pregnancy or breast feeding? |
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| Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this? |
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| Please enter any further details which you feel may be relevant |
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