Microsoft word - psd - yellow fever and travel immunisations - merged form february 2012.doc

CHURCH LANGLEY MEDICAL PRACTICE
YELLOW FEVER PRE-VACCINATION FORM (PATIENT SPECIFIC DIRECTION) (ALSO
RABIES, TICK BORNE ENCEPHALITIS, MENINGITIS ACWY)
Please complete this form and return to the surgery prior to attending for vaccination. The yellow fever certification must be issued 10 days prior to travel for it to be valid. DATES OF TRIP
Date of departure / / Return date / /
Countries with destinations to be visited Length of stay
DESCRIBE YOUR TRIP (Please tick as many as you feel are appropriate) Travelling
Staying in an area
Planned activities
Do you have any illnesses? If YES please give details

Are you taking any medication(s)? If YES please give details

Do you have any allergies for example to eggs, antibiotics, nuts or latex? If YES please give details
Have you ever had a serious reaction to a vaccine given to you before? If YES please give details

Have you had any steroid, chemotherapy or immunosuppressant drugs (i.e. Methotrexate/Cyclosporin /
Azathioprine? If YES please give details

Women only: Are you pregnant or planning pregnancy or breastfeeding? If yes please give details

VACCINATION HISTORY IF NOT RECEIVED HERE AT THE PRACTICE Have you ever had any travel vaccinations or malaria tablets from elsewhere? If so what and when? . . . CHURCH LANGLEY MEDICAL PRACTICE
I wish to be vaccinated against yellow fever / rabies / tick borne encephalitis / meningitis / ACWY (delete as necessary). I understand there is a charge for this vaccination as this is not part of the NHS provision. I have had the opportunity to discuss the suitability and side effects of the vaccine(s). Patient Signature: ______________________________________ Date: _________________ FOR PRACTICE NURSE USE ONLY Travel risk assessment performed Yes No 0, 1, 6 months (3 doses) OR
Comments………………………………………………………………………………………………………………… 2 tablets weekly starting 1 week before, during and for 4 weeks after trip 2 tablets weekly starting 1 week before, during and for 4 weeks after trip Daily starting 1 week before, during and for 4 weeks after trip Daily starting 2 days before, during and for 7 days after trip Daily starting 2 days before, during and for 7 days after trip Weekly starting 2 weeks before, during and for 4 weeks after trip Comments………………………………………………………………………………………………………………… Vaccination
Discuss requirements Malaria advice
PATIENT SPECIFIC DIRECTION (PSD)
Administration by Practice Nurse:
Patient risk assessment performed and authorised by:
Prescribers name (Dr) Signature Date / /
Date completed by Nurse: __________________ Signed: _________________________

Source: http://www.clmp.co.uk/downloads/Travel_Vaccination_Form-May_2012.pdf