COMPLETE TRAVEL FORM GREEN SECTION SAVE AND UPLOAD* TO STUDENT HEALTH VIA LINK* BELOW
Name: Click or tap here to enter text. Dob: Click or tap to enter a date. Tel. no. Click or tap here to enter text.
YOUR MEDICAL DETAILS: Enter details of Travel vaccines/Medical History/Medication/Allergies
List previous Travel Vaccines you have had?: Click or tap here to enter text.
Current illnesses OR Medical History of Note: Click or tap here to enter text.
Current medication: Click or tap here to enter text.
Allergies OR Anaphylaxis: Click or tap here to enter text.
YOUR TRAVEL DETAILS: Enter the details of your trip- When, Where, and for how long are you going?
Date of departure: Click or tap to enter a date. Total duration of stay:Click or tap here to enter text.
Destination(s) in order: Click or tap here to enter text.
Type of trip: Choose an item. Malarial area? ☐ Visiting an area at altitude >3000m? ☐
PLESE READ TRAVEL HEALTH WEBSITES TO LEARN OF HEALTH RISKS e.g. www.fitfortravel.nhs.uk
THE TABLE BELOW WILL BE COMPLETED BY STUDENT HEALTH AT YOUR TRAVEL CONSULTATION Note a Fee of 30 Euro applies for your initial consultation. All Vaccines to be paid for in advance
Vaccinations recommended for ALL travellers detailing cost of each course
Infections Targeted	Vaccine Name	No. of doses	Cost per course	Interval btw doses (days)	Recommended	Booster Due
Diphtheria Tetanus Polio (Pertussis)	Revaxis or (Boostrix )	1	35	0	10yrs +
Hepatitis A	Avaxim	1	40	0	6-12 Months
Typhoid	Typhim	1	35	0	3 Years
Vaccinations recommended for CERTAIN travellers detailing cost of each course
Illness	Vaccine Name	No. of doses	Cost per course	Interval btw doses (days)	Recommended	Booster Due
Rabies	Verorab	3	105	0,7,21/28	If bitten
Hepatitis B	Engerix B	3	120	0,7,21	12 months
Yellow Fever	Stamaril	1	40	0	Lifelong Protection
Meningococcal ACWY	Nimenrix	1	60	0	5 years
Measles Mumps Rubella	MMRVaxPro	1 or 2	Free	28	Lifelong Protection
Medication Recommended as Precautionary Supply: (tick any that apply)
Cetirizine ☐	Motilium ☐	Loperamide ☐	Fucibet ☐	Others:
Medication Recommended for Malarial Prophylaxis – Consider destination, side effect profile, and costs
Medication	DOXYCYCLINE*	MALARONE
Side Effects	(Relatively common. Not usually serious) Nausea /Vomiting/Diarrhoea/Dyspepsia/Thrush/Sunburn	(Relatively rare. Not usually serious) Nausea /Vomiting/Diarrhoea//Depression/Nightmares
Dosage	1 daily. Begin 2 days before enter area and continue daily until you stop 28 days after leaving area.	1 daily. Begin 2 days before enter area and continue daily until you stop 6 days after leaving area.

* A trial dose of Doxycycline is recommended 2-3 weeks pre-departure, to determine if tolerable and to ensure no significant side effects occur.

Note all anti-malarial medication is available to full Medical Card holders for Prescription Charge only Discuss cost with Pharmacist.

*COMPLETE THE GREEN SECTON ABOVE ANDP UPLOAD TO US VIA https://www.ucc.ie/en/studenthealth/yourhealthdata/accessing/