PORTESHAM SURGERY PRE-TRAVEL ASSESSMENT …



PORTESHAM SURGERY PRE-TRAVEL ASSESSMENT QUESTIONNAIRE * PLEASE COMPLETE AS MUCH INFORMATION AS POSSIBLE (PATIENT/RECEPTIONIST PRIOR TO APPT)NAME: DATE OF BIRTH: DAY TIME CONTACT TEL NUMBER:GP:DEPARTURE DATE **RETURN DATE **ALL COUNTRIES/AREAS TO BE VISITED OR TRAVELLING THROUGH LENGTH OF STAY IN EACH1.2.3.PURPOSE OF TRIPHOLIDAY TYPEACCOMODATIONTRAVELLING FORMCHECKBOX Pleasure FORMCHECKBOX Package FORMCHECKBOX Hotel FORMCHECKBOX Alone FORMCHECKBOX Work FORMCHECKBOX Trekking or backpacking FORMCHECKBOX Relatives/private home FORMCHECKBOX With family/friend FORMCHECKBOX Visiting family/friends FORMCHECKBOX Safari FORMCHECKBOX Lodge/tent FORMCHECKBOX In a group FORMCHECKBOX Business/other FORMCHECKBOX Cruise FORMCHECKBOX Ship/otherIF YOU REQUIRE MALARIA TABLETS FOR YOUR TRIP, YOU MAY HAVE TO SEE YOUR GP FOR A PRESCRIPTION. THE PRACTICE NURSE WILL ADVISE YOU IF YOU ARE NOT SURE.IF A YELLOW FEVER VACCINATION IS RECOMMENDED FOR YOUR TRIP, THIS VACCINE HAS TO BE GIVEN AT A REGISTERED YELLOW FEVER CENTRE, SUCH AS WYKE/PUDDLETOWN OR THE BRIDGES MEDICAL CENTRE AND IS CHARGEABLE.PLEASE REMEMBER TO ALLOW PLENTY OF TIME TO COMPLETE THE VACCINATIONS BEFORE YOUR DEPARTURE. MORE THAN ONE VISIT MAY BE NECESSARY FOR COMPLICATED ITINERARIES.TRAVEL VACCINATIONS UNDER PATIENT SPECIFIC DIRECTION- PORTESHAM SURGERY*NURSE TO COMPLETE THIS PAGE VACCINE HAD RECOMMENDEDCONSIDERDATEGIVEN AT PORTESHAM COSTTETANUS/DIPHTHERIA & POLIO FREETYPHOID FREE HEPATITIS A 1ST FREEPAEDIATRIC HEP A FREEBOOSTER HEP A FREEHEPATITIS B COURSECHARGEABLE-APPROX ?60-75)HEPATITIS B BOOSTERCHARGEABLE- ?20-?25CHOLERA (ORAL) MAY BE CHARGEABLERABIES BOOSTERCHARGEABLE-?55RABIES COURSECHARGEABLE-?160-?170MENINGOCOCCAL MENINGITIS ACWYCHARGEABLE-?30-?35MENINGOCOCCAL MENINGITIS MENVEOCHARGEABLE-?60-?65TICK BOURNE ENCEPHALITISCHARGEABLEJAPANESE ENCEPHALITIS COURSE (Ixiaro) COURSE OF 2 OR 3CHARGEABLE-?185-?275 APPROXJAPANESE ENCEPHALITIS BOOSTERCHARGEABLE-?90-?95YELLOW FEVER-REFER TO REGISTERED CENTRENA (USUALLY ?50-65)MALARIA TABLETSCHARGEABLEOTHER ADVICE DISCUSSED OR LEAFLET GIVENLONGHAUL FLIGHT/DVT/SOCKSINSURANCE Y/NPATIENT SIGNATURE (CONSENT):BITE PREVENTION/REPELLANTPERSONAL SAFETY Y/NNURSE SIGNATURE:DRINK/FOOD HYGIENESUN/HEAT STROKE Y/NGP SIGNATURE:ALTITUDEPRE TRAVEL HEALTH/BP ETC/MEDSFIRST AID/MEDICATIONALLERGIES Y/N ................
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