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HW+ Health and Wellbeing Plus | Travel Vaccines

Yellow Fever Checklist

This pre-vaccination checklist assists your healthcare professional to assess the risk of giving you yellow fever vaccine, they must review the checklist to ensure the vaccine is safe for you.

UK &

Checklist: Yellow Fever Vaccine

This pre-vaccination checklist assists your healthcare professional to assess the risk of giving you yellow fever vaccine, they must review the checklist to ensure the vaccine is safe for you. If you have any questions, concerns or do not understand anything please ask your healthcare professional to explain during your consultation. If you answer ‘yes’ to any questions, you need to give more details during your consultation. To read more about why these questions are important, please see page 3 and page 4 of this form.

Birthday
Day
Month
Year
Are you feeling well today?
Yes
No
Do you have any allergies, particularly to eggs or chicken protein?
Yes
No
Have you ever reacted to a previous yellow fever vaccine?
Yes
No
Do you have cancer or have you had cancer in the past (even if it was a long time ago)?
Yes
No
Do you have any illness that might affect your immune system?
Yes
No

For example, leukaemias, lymphoma, cellular immune deficiencies, chronic lymphoproliferative conditions, or if you have ever received a stem cell transplant.

Are you living with HIV?
Yes
No
Are you taking any medicines (now or within the last year) that affect your immune system?
Yes
No

For example, steroids, biological or non-biological immune modulating medicines, treatment following an organ transplant.

Are you having chemotherapy or radiotherapy (now or within the last year)?
Yes
No
Have you ever been told that you may have a problem with your thymus gland (includes myasthenia gravis or a thymoma)?
Yes
No
Have you had an operation to remove your thymus gland (thymectomy) for any reason including during cardiac surgery?
Yes
No
Have you ever had open chest surgery?
Yes
No
Are you pregnant or planning a pregnancy?
Yes
No
Are you breast feeding?
Yes
No
Do you have a first-degree family relative (i.e. a blood relative – mother, father, full brother, sister or child) who has had a serious adverse reaction to Yellow Fever Vaccine?
Yes
No

I have read the above and confirm that the questions have been answered to the best of my knowledge.

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