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THE LAKES MEDICAL CENTRE
21 CHORLEY ROAD,
SWINTON, MANCHESTER M27 4AF


Name…………………………………. D.O.B…………………………AGE………
Address……………………………………………………………………………….
Own GP name…………………………………………………………………………
Address…………………………………………………………………………………

Contact No. home/work……………………………………………………………….

Destination/ date of departure/ Length of stay/ Reason for travel ……………….

……………………………………………………………………………………….
If you suffer from any of the following problems the Yellow Fever vaccination should
not be administered to you. We would therefore be grateful if you would confirm that
none of the following apply to you. (Please delete as appropriate)
2. Treatment with steroids or immuno-suppressive treatment (as administered for cancers and in certain instances, athritic and other conditions. Yes/No 3. Use of anabolic steroids Yes/No 4. Have you had oral steroids within the last 3 months Yes/No 5. Conditions such as leukaemia, Hodgkin’s Disease or other malignant conditions Yes/No 6. Conditions that reduce immunity to infection including AIDS/HIV+. Yes/No 7. Sensitivity to Neomycin, Polymyxin, Egg or Chick protein. Yes/No 8. Pregnant. Yes/No 9. Have you had any disorders of your thymus gland including myasthenia gravis, Thyoma, Thymectomy or DiGeorge Syndrome Yes/No 10. Do you take methotrexate or azathioprine therapy? Yes/No 11. Have you been prescribed or used Tacrolimus (Protopic) or Yes/No Pimecrolimus (Elidel) creams in the last 28 days? Current medications: ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………
Caution
10. Aged over 60 years Yes/No
In addition the vaccine should not be given within 3 weeks of having the MMR
vaccination. Please therefore confirm the types and dates of any other vaccinations
received.
………………………………………………………………………………………….
………………………………………………………………………………………….
I have read the above information and confirm accordingly that there is no reason why
I should not be vaccinated for Yellow Fever.
I understand that if after consultation I decide not to proceed with the immunisation a
consultation fee of approximately half the whole charge will be levied, and I am
responsible for this payment.
Signed……………………………………………… Date ………………………….
To be completed by clinician:

Patient Specific Prescription for Yellow Fever Vaccination
GP signature…………………………………………Date……………………………
Possible S.E discussed, No contraindications vaccine (Y/F batch site Exp date)
Malaria advice
Nurse signature ………………………………………Date ………………………….

Source: http://www.thelakesmedicalcentre.co.uk/website/P87025/files/yellowfeverform.pdf

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