VACCINATION QUESTIONNAIRE

               AND INSTRUCTIONS FOR TRAVEL ABROAD

 Name (in capital letters please):..........................................................................................................................

 Date of Birth:..........................................................Nationality..........................................................................

 Address:............................................................................................................................................................

 Workplace:.......................................................................................................................................................

 TAJ No:(If you have Hungarian Insurance )...........................................................................................................

 Please read carefully before providing the information requested. Your answers will tell us your probable

 reactions to  vaccines and help determine whether you can be given a particular vaccine. 

1. Planned Itinerary  (Please state the countries you plane to visit and number of days you plane to spend in  each)

 ......................................................................................................................................................................................................................................

 2. Time of departure:.........................................................................................................................................................................................................

 3. Please underline how you are traveling : alone    with family    in a group

     Any children traveling with you ?     Yes (age?)                                       No

 4. Reason for Travel (underline) :  Rest   -  Businnes  -Study  -  Extended Stay   -    Nature  -  Experience  -  Family visit  - 

City Adventure  -  Extreme Sports    -   Mountain  Travel

 5. Accomodations :  Hotel (luxory/modest)  -  Youth Hostel  -  Camping (official/rough )

 6. Personal information:

Chronic Illnesses ( e.g.: Diabetes, asthma, heart disease, pacemaker, hypertonic, immunicompromised, recent operation):

  ....................................................................................................................................................................................................................

Past Illnesses :.............................................................................................................................................................................................................. 

Current Medications:.....................................................................................................................................................................................................................

    Allergies:.................................................................................................................................................................................................................................... 

     Have you ever felt ill when your blood was drawn or were vaccinated ?    Yes       No

     Please list the vaccination you have  had to date for travel

               (Do you have a vaccination card?)...........................................................................................................................

      Are you pregnant ?      Yes       No

 8. Please underline the vaccinations you need for your current travels (the doctor willing to help you):

  Yellow Fever (9945HUF)    Hepatitis A (8470HUF)    Hepatitis A pediatrix (    HUF)

  HepatitisB (4460HUF)   Hep A+B (8810HUF)         Typhoid (7015HUF)   

  Tetanus (2145HUF)          Di-Per-Te (HUF)       Di-Per-Te-IPV (7595HUF)  Varicella (9190HUF)

  Meningococcal meningitis conjugated (11820HUF)      Rabies (HUF)      Influenza  ( 2600HUF)   

  Measles - Mumps - Rubeola  (MMR) (9610HUF)   Tick - Borne Encephalitis (7535HUF)              

  You may need series of shots for a complete immunization (e.g.: hepatitis A,B. rabies)                                             

   Compulsory medical consultation: 3800 HUF , children: 2000 HUF

  9. Malaria Prophylaxis and information :

  10. Other medication:

I accept the patient will be billed according to the price list ont he chart.  The bill is written in Hungarian language. Payment is needed in HUF (cash) after the vaccination at the cashier.

I was properly informed about the benefits, dangers, side effects and possible reactions I may have to the vaccines given and insructed to wait 30 minutes before leaving the premises.

 Dated :                                      Signed :

 Updated: 2018