Travel Vaccination Questionnaire River Brook Medical Centre Personal Details



Download 60 Kb.
Date02.06.2016
Size60 Kb.
Travel Vaccination Questionnaire River Brook Medical Centre
Personal Details
Name:
Date of Birth:
Male: Female:
Telephone Number:

Dates of Trip: From: To:



Return date or overall length of trip:
Itinerary and purpose of visit


Countries to be visited


Length of stay

Away from medical help

at destination, if so, how

Remote?


1.







2.







3.







Any future travel plans?




Please tick as appropriate below to best describe your trip

Type of trip

Business




Pleasure




Other




Holiday type


Package





Self organised




Backpacking




Camping





Cruise ship




Trekking




Accommodation


Hotel




Relatives/family home




Other




Travelling

Alone




With family/friend




In a group




Staying in an area which is


Urban




Rural




Altitude




Planned activities

Safari




Adventure




Other





Travel Vaccination Questionnaire River Brook Medical Centre

Personal Medical History


Do you have any recent or past medical history of note?(including diabetes, heart or lung conditions)





List any current or repeat medications





Do you have any allergies for example to eggs, antibiotics, nuts or latex?





Have you ever had a serious reaction to a vaccine given to you before?





Does having an injection make you feel faint?




Do you or any close family member have epilepsy?




Do you have any history or mental illness depression or anxiety?




Have you recently undergone radiotherapy, chemotherapy or steroid treatment?




Women only: Are you pregnant or planning pregnancy or breastfeeding





Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?


Please write down any further information which may be relevant







Vaccination History

Tetanus




Polio




Diphtheria




Typhoid




Hepatitis A




Hepatitis B




Meningitis




Yellow Fever




Influenza




Rabies




Jap B

Enceph





Tick Borne




Other:

Malaria Tablets:

Have you ever had any of the following vaccinations/malaria tablets and if so when?

For discussion when risk assessment is performed within your appointment:


I have no reason to think that I might be pregnant. I have explained information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.
Signed: Date:

Travel Vaccination Questionnaire River Brook Medical Centre


FOR OFFICIAL USE

Patient Name:

Travel risk assessment performed: Yes: ………. No: ……….

Travel Vaccines recommended for this trip




Disease protection

Yes

No

Patient declined vaccine

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

Food, Water

and personal hygiene advice






Travellers’ Diarrhoea




Blood and bodily fluid infection risks e.g. Hepatitis B




Insect bite prevention




Animal bites




Accidents




Insurance




Air Travel




Sun and heat protection




Websites




SMS Vaccines reminder service set up




Travel record card supplied




Other




Malaria prevention advice and malaria chemoprophylaxis

Chloroquine and proguanil




Atovaquone + proguanil




Chloroquine




Mefloquine




Doxycycline




Malaria advice leaflet given







Further Information

e.g. weight of child





Travel Vaccination Questionnaire River Brook Medical Centre




Authorisation for Patient Specific Direction (PSD) Use

Assessor’s Name: Signature: Date:

Prescriber’s Name: Signature: Date:





Share with your friends:




The database is protected by copyright ©essaydocs.org 2020
send message

    Main page