To be retuned at least 2 working days prior to appointment with nurse.
Please complete this form prior to your travel appointment and return to reception. Personal Details
Name: _______________________________________________________________________________________________ Date of birth:
_______________________________________________________________________________________________ Contact telephone number:
Email: GP name and address (if not registered at this surgery):
Dates of trip Departure:
Itinerary and purpose of visit
Country to be visited
_____________________________________________________________________________ 1. _________________________________________________________________________________________________ 2. _________________________________________________________________________________________________ 3.
Please circle the descriptions that best describe your trip
1. Type of trip:
Personal medical history (please supply printout from own GP)
Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder _________________________________________________________________________________________________ List any current or repeat medications _________________________________________________________________________________________________ Do you have any allergies, for example to eggs, antibiotics, nuts, etc.? _________________________________________________________________________________________________ Have you ever had a serious reaction to a vaccine given to you before? ________________________________________________________________________________________________ Do you or any close family members have epilepsy? _________________________________________________________________________________________________ Do you have any history of mental illness, including depression or anxiety? _________________________________________________________________________________________________ Have you recently undergone radiotherapy, chemotherapy or steroid treatment? ________________________________________________________________________________________________ Women only: Are you pregnant or planning pregnancy or breast feeding? ________________________________________________________________________________________________ Please give any further information that may be relevant, including any future travel plans: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Vaccination history
Have you ever had any of the following vaccinations/medication previously for travel? If so, when approximately? Vaccination
Hepatitis A _________________________________________________________________________________________________ Hepatitis A Booster _________________________________________________________________________________________________ Hepatitis B:
_________________________________________________________________________________________________ Japanese Encephalitis
_________________________________________________________________________________________________ Malaria tablets _________________________________________________________________________________________________ Meningitis _________________________________________________________________________________________________ Rabies
________________________________________________________________________________________________ Typhoid _________________________________________________________________________________________________ Yellow Fever
_________________________________________________________________________________________________ Yellow Fever Booster _________________________________________________________________________________________________ Childhood vaccinations, e.g. Tetanus _________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
FOR OFFICIAL USE
Patient name: Travel risk assessment performed: yes/no Travel vaccines recommended for this trip: Disease protection Yes/No/Further Information
Hepatitis A Hepatitis B Typhoid Cholera Tetanus Diphtheria Polio Meningitis ACWY Yellow Fever Rabies Japanese B Encephalitis Other Travel advice and leaflets given as per travel protocol
Malaria prevention advice and malaria chemoprophylaxis
Food, water and personal hygiene advice/ Travellers’ diarrhoea/ Hepatitis B, C and HIV Insect bite prevention/ animal bites/ accidents/ Insurance/ Air travel/ Sun and heat protection/ Hajj travel/ Travel record supplied Websites
Other Chloroquine and proguanil/ Atovaquone & proguanil (Malarone)/ Chloroquine/ Mefloquine/ Doxycycline/ Malaria advice leaflet given Further information Nurses Signature: …………………………………………………………………………………………………………. _____________________________________________________________________________ For discussion when risk assessment is performed within your appointment:
I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I have been advised that I will be charged a fee for these vaccinations – see annex for charges. I have been made aware that some of these vaccines may be available free from my own GP, however I have chosen to be treated privately. I consent to the vaccines being given. Signed:……………………………………………………………………………………Date:………………………………………… .
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