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Travel detailsIn order first to lastDate of DepartureTotal DurationCountry : Area to be visited:3896360-31686500Date Form Completed:- Date Completed by Practice Nurse:-Date of appointment with Practice Nurse:-East Riding Pre-Travel Health Questionnaire-6604011430Please complete a form for each member of your party/family. Complete the questionnaire at least 4 weeks prior to your date of departure where possible. Please note you may be advised to seek assistance from a Travel Clinic if you are a last minute traveller.00Please complete a form for each member of your party/family. Complete the questionnaire at least 4 weeks prior to your date of departure where possible. Please note you may be advised to seek assistance from a Travel Clinic if you are a last minute traveller.-66040132080Personal detailsName :- Title:-DOB:-Home Address:-Home Tel No:-Mobile:-Postcode:-Email:-GP Address:-00Personal detailsName :- Title:-DOB:-Home Address:-Home Tel No:-Mobile:-Postcode:-Email:-GP Address:-Current Health Problem Medical HistoryMedicationDo any of the following apply to youYesNoPull down current medsPregnant, breast feeding, Plan to become pregnant within three months of travelHave a problem with your Immune Systeme.g.: Thymus ProblemsCardiac ProblemsSpleen removedType of Trip and purpose of visit – Please Type of TripPackageCruise ShipCampingBackpackingHoneymoonOther Please SpecifyVoluntary Charity WorkTrekkingAccommodationHotel/CruiseFamily / Friends HomePlanned ActivitiesSafariOther – Please Specify Vaccination History – Any Previous Vaccinations especially from another PracticeTRAVEL VACCINATION CHARGESAs of July 2020VaccinationCostNotesYellow FeverCertificateTotal Cost ?71.00?14.00 + ?2.80 Vat?87.80Hepatitis B 1st 2nd 3rd Booster?49.00?27.00?27.00?49.00Travellers AbroadMeningitis Nimenrix?64.00Travellers AbroadRabies 1st 2nd 3rd Booster?80.00?63.00?63.00?80.00Travellers AbroadJapanese EncephalitisPrices vary (~?107)Please ask for detailsFor courses of three injectionsTickbourne EncephalitisPrices vary (~?170)Please ask for detailsFor courses of three injectionsTo be completed by the Practice NurseAdditional InformationNational database consulted for travel vaccines recommended for this trip and malaria chemoprophylaxis (ire required): NaTHNaC: TRAVAX: OTHER:Disease Protection AdvisedRequiredRecommendedTo be consideredDisease Protection AdvisedRequiredRecommendedTo be consideredBCG/ManutouxInfluenzaCholeraMeningitis ACWYDip/tetanus/polioMMRHepatitis ARabiesHepatitis BTickbourne EncephalitisHepatitis A+BTyphoidHepatitis A + TyphoidYellow FeverJapanese EncephalitisOtherAtovaquone/proguanilDoxycyclineChloroquine onlyMefloquineChloroquine and proguanilProguanil onlyDoxycyclineEmergency standbyMefloquineWeight of child:Vaccine and General Travel Advice required/providedPotential side effects of vaccines discussedPatient Information Leaflet from packaging or from .uk/emc/ given Yes/NOOrdering of vaccinesBased on information given by the nurse patient has decided to have the following vaccines:Patient agrees vaccine charges with nursePatient pays for vaccinesInformation passed to dispensary to order vaccinesExpected date in of vaccinesLocation of vaccinesTo be completed by the Practice NurseAuthorisation for a Patient Specific Direction (PSD)Following the completion of the travel risk assessment, the below named vaccines may be administered under this PSD to:Name:DOB:Name, form & strength of medicine (generic/brand name as appropriate)Dose, schedule and route of administrationStart and finish datesSignature of prescriberDate ................
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