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SECTION ONE - TO BE COMPLETED BY PATIENTName: FORMTEXT ?????DOB: FORMTEXT ????? Sex:Male FORMCHECKBOX Female FORMCHECKBOX Address: FORMTEXT ?????GP: FORMTEXT ?????GP Address: FORMTEXT ?????Postcode: FORMTEXT ?????Postcode: FORMTEXT ?????Tel No. FORMTEXT ?????Tel No. FORMTEXT ?????Current Health Problems: FORMTEXT ?????Past Medical History of note? Or currently undergoing chemotherapy/ radiotherapy/ steriod treatment?: FORMTEXT ?????Current Medication: FORMTEXT ?????Allergies (e.g. eggs, antibiotics, nuts,latex): FORMTEXT ?????Have you ever had a serious reaction to a vaccine given to you before? Yes FORMCHECKBOX No FORMCHECKBOX Pregnancy? Yes FORMCHECKBOX No. of weeks: FORMTEXT ????? ?No FORMCHECKBOX N/A FORMCHECKBOX TRAVEL DETAILS: (in order first to last)Date of Departure: FORMTEXT ?????Total duration: FORMTEXT ?????DestinationLength of Stay FORMTEXT ????? FORMTEXT ?????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of trip (please tick all that apply)Areas VisitingAccommodation FORMCHECKBOX Travelling with Family FORMCHECKBOX Travelling with Friends FORMCHECKBOX Travelling Alone FORMCHECKBOX Urban FORMCHECKBOX Rural FORMCHECKBOX Altitude FORMCHECKBOX Beach FORMCHECKBOX Good FORMCHECKBOX Basic FORMCHECKBOX Poor FORMCHECKBOX Not Known FORMCHECKBOX Package Holiday FORMCHECKBOX Immigration FORMCHECKBOX Voluntary/ Charity Work FORMCHECKBOX Cruise FORMCHECKBOX Organised Adventure FORMCHECKBOX Elective/ Student FORMCHECKBOX Business <3 Months FORMCHECKBOX Backpacking FORMCHECKBOX Aid Worker FORMCHECKBOX Business >3 Months FORMCHECKBOX Visiting family/friends FORMCHECKBOX Self Organised Occupation/Activities Abroad: FORMTEXT ?????Vaccination History Have you ever had any of the following vaccinations / malaria tablets and if so when?Tetanus FORMCHECKBOX ? FORMTEXT ?????Meningitis FORMCHECKBOX ? FORMTEXT ?????Hepatitis A FORMCHECKBOX FORMTEXT ?????Polio FORMCHECKBOX ? FORMTEXT ?????Yellow Fever FORMCHECKBOX ? FORMTEXT ?????Hepatitis B FORMCHECKBOX FORMTEXT ?????Diphtheria FORMCHECKBOX ? FORMTEXT ?????Influenza FORMCHECKBOX ? FORMTEXT ?????Jab B Enceph FORMCHECKBOX FORMTEXT ?????Typhoid FORMCHECKBOX ? FORMTEXT ?????Rabies FORMCHECKBOX ? FORMTEXT ?????Tick Borne FORMCHECKBOX FORMTEXT ?????Other: FORMTEXT ?????Malaria Tablets: FORMTEXT ?????PLEASE NOTE: Some Vaccines/Malaria Tablets are not covered by the NHS and will incur a charge; this will be discussed before the vaccines are given. There may be a charge for private patients.PLEASE BRING THE COMPLETED QUESTIONNAIRE TO YOUR APPOINTMENT WITH THE TRAVEL NURSE.SECTION TWO - TO BE COMPLETED BY HEALTHCARE PROFESSIONALPatient Name: FORMTEXT ?????Patient Advised of Possible Private Charge? Yes FORMCHECKBOX No FORMCHECKBOX Travel Risk Assessment Performed Yes FORMCHECKBOX No FORMCHECKBOX ‘I Consent to the Vaccinations being Given’ Patient Signature: FORMTEXT ?????Travel vaccines recommended for this trip *Possible private cost, not covered by NHSDisease ProtectionYesNoPatient DeclinedFurther Information/ ScheduleHepatitis A FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ??????Hepatitis B* FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Typhoid FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Cholera FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Tetanus FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Diphtheria FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Polio FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????MMR (Measles, Mumps, Rubella)* FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Meningitis ACWY* FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Yellow Fever* FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Rabies* FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Japanese B Encephalitis* FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Malaria Prevention advice and malaria chemoprophylaxis*Chloroquine and proguanil FORMTEXT ??????Atovaquone + Proguanil FORMTEXT ?????Chloroquine FORMTEXT ?????Mefloquine FORMTEXT ??????Doxycycline FORMTEXT ?????Malaria advice leaflet given FORMTEXT ?????Travel Advice/ Risks Discussed/ Leaflets givenAdvice/RiskYes No N/AAdvice/Risk Yes No N/ABite Avoidance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Schistosomiasis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Food/Water Hygiene FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Insurance/Accidents FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Blood Borne Viruses FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sun Protection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Rabies FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Air Travel FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traveler's Diarrhoea FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bodily Fluid Infections? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (Please Specify) FORMTEXT ?????Further Information? FORMTEXT ?????Completed By: FORMTEXT ?????Date: FORMTEXT ????? ................
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