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Travel_questionnaire sept 1

Branksomewood Healthcare Centre
TRAVEL VACCINATION QUESTIONNAIRE
PATIENT TO COMPLETE THIS SIDE
DOB. GP………………….

DAYTIME CONTACT TEL NO.
PLEASE LIST ALL COUNTRIES TO BE VISITED - IN ORDER- INCLUDING STOP-OVERS
LENGTH OF STAY

What type of accommodation are you staying in? Hotel / Self -Catering / Backpacking/Cruise
Reason for travel? Holiday / Work / Gap Year / Visiting Friends and Family
ARE YOU OR DO YOU HAVE ANY OF THE FOLLOWING? :-
HISTORY OF PSYCHIATRIC ILLNESS including anxiety/depression Have you ever had any of the following vaccinations and if so when? Please bring any
records of vaccines you’ve had with you to the appointment.

I have answered these questions correctly to the best of my knowledge
PATIENT OR PARENT/GUARDIAN SIGNATURE.

There is a charge for some vaccines with no exemptions available
We are unable to accept credit or debit cards for payment.
Payment will be expected on the day of appointment
Branksomewood Healthcare Centre
TRAVEL VACCINATION QUESTIONNAIRE
NURSE TO COMPLETE THIS SIDE
REQUIRED
TETANUS,
DIPHTHERIA & POLIO
TYPHOID

HEPATITIS A
YELLOW FEVER
MENINGITIS ACW &Y
£50 (2doses orally)
HEPATITIS B
£35 per injection
(initially course of 3 required)
£45 per injection
(3 Injections per course)
JAPANESE
£80 per injection
ENCEPHALITIS
(2 injections per course)
TICK-BORNE
£65 per injection
ENCEPHALITIS
(3 injections per course)
I give authorisation for practice nursing staff
Signature
to administer a vaccine or course of any of
the above vaccines which are not covered by
Hampshire PCT patient group directions
MALARIAL PROPHYLAXIS
Weight of Child under 16yrs
Recommended
CHLOROQUINE
Buy from chemist
PROGUANIL
Buy from chemist
MALARONE
£15.00 for private script + cost of tablets
DOXYCYCLINE
£15.00 for private script + cost of tablets
MEFLOQUINE
£15.00 for private script + cost of tablets
Insect bite Avoidance
Travel Appointment needed? Yes/ No
Length of Appointment 10mins/ 20mins/ Not required and appt cancelled
Comments----------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------

ADVICE GIVEN
Food & Water Hygiene
Altitude Sickness Yes / No
Animal bites
Sun and Heat
Hepatitis B & HIV
Insurance

P drive forms travel questionnaire

Source: http://www.branksomewood.co.uk/downloads/travel_questionnaire-sept11.pdf

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7 gute Gründe, um als Paar die Erotik zu pflegen Die Sexualität ist eine wunderbare Erfindung der Natur, die eine Quelle von Freude, Lust und Lebendigkeit mit unserem Partner sein kann. Sie wird aber auch schnell gestört, wenn Paare Beziehungsprobleme entwickeln. Gleichzeitig hat Sexualität eine enorme Kraft, um positive Veränderungen zu unterstützen. Die Erotik ist deshalb auch in u

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