Yellow Fever Checklist

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.
Q1 How old are you?
Q2 Are you feeling unwell today? Yes No
Q3 Do you have any allergies, particularly to eggs or chicken protein? Yes No
Q4 Have you ever reacted to a previous yellow fever vaccine? Yes No
Q5 Do you have cancer or have you had cancer in the past

(even if it was a long time ago)? Yes No
Q6 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.
Q7 Are you living with HIV? Yes No
Q8 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.
Q9 Are you having chemotherapy or radiotherapy (now or within

the last year)? Yes No
1
Q10 Have you ever been told that you may have a problem with
your thymus gland (includes myasthenia gravis or a thymoma)? Yes No
Q11 Have you had an operation to remove your thymus gland

(thymectomy) for any reason including during cardiac surgery? Yes No
Q12 Have you ever had open chest surgery? Yes No
Q13 Are you pregnant or planning a pregnancy? Yes No
Q14 Are you breast feeding? Yes No
Q15 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.
Name of patient Signature of patient Date (dd/mm/yy)
If applicable
Name of parent/guardian Signature of parent/guardian Date (dd/mm/yy)
Form reviewed and risk assessment carried out by
Reviewed by Qualifications Date (dd/mm/yy)
2
Why are these questions important?
How old you are
Babies
• There is a greater risk of yellow fever vaccine related brain inflammation (encephalitis)
in very young babies. Babies aged less than six months should not have yellow fever
vaccine and babies aged six to nine months should only be given this vaccine if the
risk of yellow fever at the destination to be visited is high, such as during epidemics/
outbreaks, and travel is unavoidable.
Aged 60 years or older

• You are at increased risk of developing serious side effects from the vaccine compared
to younger travellers. If you are travelling to areas where yellow fever vaccine is
‘generally not recommended’ you should not receive vaccine. Further information is
available in the NaTHNaC Yellow Fever Information Leaflet for Travellers and on the
FitForTravel Yellow Fever Vaccine page.
How you are feeling today

• Minor illness without high temperature (fever) should not usually delay your yellow fever
vaccination. However, vaccination may be postponed until you have fully recovered. This
is to make sure any symptoms are not confused with possible reactions to the vaccine.
Your allergies and previous reactions to yellow fever vaccine

• This vaccine may contain traces of egg, chicken protein and other ingredients that some
people are occasionally allergic to. If you have ever had a serious reaction (anaphylaxis)
to any of the vaccine ingredients, you must tell your health professional. If you have
an ongoing allergy to egg, you may need to be assessed by a trained allergy specialist
or immunologist and vaccinated in a hospital setting. If you have other allergies to the
vaccine ingredients, you may not be able to have the vaccine.
Your general health and any condition or treatment that may

affect your immune system
• This vaccine contains live yellow fever virus that has been weakened. Your response to
the vaccine may not be so good if your immune system is weakened by certain illnesses
or treatments, but occasionally the vaccine can still be given. However, if your immune
system is very weak you must not receive yellow fever vaccine as you are at risk of
developing serious side effects from the vaccine, including death.
3
If you have ever been told that you may have a problem with your
thymus gland (includes myasthenia gravis or a thymoma), or if you
ever had open chest surgery
• The thymus gland is part of your immune system and sometimes does not work properly
or has been removed (thymectomy). Certain conditions such as Myasthenia gravis may
involve your thymus gland. If you have a history of any of these conditions, you must
not receive yellow fever vaccine as you are at risk of developing serious side effects,
including death.
• The thymus gland may be removed during chest surgery. Your surgical notes and current
guidance for health professionals may need to be reviewed to establish if your thymus
gland was removed. Yellow fever vaccine can still be given in some instances following
chest surgery where the thymus gland remains.
If you are planning a pregnancy, pregnant now or breast-feeding

• If you are planning a pregnancy, it is recommended to wait until 28 days after yellow
fever vaccination before getting pregnant (conceiving).
• Safety of yellow fever vaccine during pregnancy is not clear, although increased
complications for mother or baby have not been reported when the vaccine was given
during pregnancy. Discussion with a health professional about the risks and benefits of
this vaccine during pregnancy will help you decide whether yellow fever vaccination is
right for you at this time.
• You are encouraged to continue breast-feeding during your trip. Several very young (less
than two months old) breast-fed babies developed brain inflammation shortly after their
mothers’ yellow fever vaccination. Discuss with a health professional whether the risk of
yellow fever at your travel destination is sufficiently high for yellow fever vaccination to
be recommended.
If you have a first-degree family member who has had a serious

adverse reaction to yellow fever vaccine
• If you have a first-degree family member (e.g mother, father, brother, sister or child) who
has experienced a serious adverse reaction and this was not due to a known medical risk
factor, it is possible that you may be susceptible to developing a serious adverse reaction
due to an unidentified genetic reason. Serious adverse reactions which may have a genetic
link include severe nervous system reactions or a reaction that stops several body organs
such as the liver, lungs and kidneys working. These are very rare.
4
! If you cannot have the yellow fever vaccination, and travel to areas where
yellow fever occurs cannot be avoided, you still need advice about yellow fever
certificate requirements and how to avoid mosquito bites.
Please check the following websites for further information and updates:
• TravelHealthPro – www.travelhealthpro.org.uk/countries
• Fit for Travel – www.fitfortravel.nhs.uk/yellow-fever-vaccine
For healthcare professionals:
• TravelHealthPro – www.travelhealthpro.org.uk
• TRAVAX (Scotland) – www.travax.nhs.uk/yellow-fever
February 2024

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Checklist: yellow fever vaccine

Q1 How old are you?

Q2 Are you feeling unwell today? Yes No

Q3 Do you have any allergies, particularly to eggs or chicken protein? Yes No

Q4 Have you ever reacted to a previous yellow fever vaccine? Yes No

Q5 Do you have cancer or have you had cancer in the past

Q7 Are you living with HIV? Yes No

Q9 Are you having chemotherapy or radiotherapy (now or within

Q11 Have you had an operation to remove your thymus gland

Q12 Have you ever had open chest surgery? Yes No

Q13 Are you pregnant or planning a pregnancy? Yes No

Q14 Are you breast feeding? Yes No

Q15 Do you have a first-degree family relative (i.e. a blood relative –

Name of patient Signature of patient Date (dd/mm/yy)

Form reviewed and risk assessment carried out by

Reviewed by Qualifications Date (dd/mm/yy)

Aged 60 years or older

How you are feeling today

Your allergies and previous reactions to yellow fever vaccine

Your general health and any condition or treatment that may

If you are planning a pregnancy, pregnant now or breast-feeding

If you have a first-degree family member who has had a serious

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