Wheal northey surgery 1 wheal northey st austell pl25 3ef
Wheal Northey Surgery 1 Wheal Northey St Austell PL25 3EF
Travel Risk Assessment Form Please complete this form prior to your travel appointment and return to reception Personal details: Name: ……………………………………………………………………………… Date of Birth: ……………………………. Male ( ) Female ( ) Easiest contact telephone number: …………………………………………………. Dates of trip: Date of departure: ………………………. Return date or overall length of trip: ………………………………………………. Itinery and purpose of visit: Country to be visited
Away from medical help at destination? If so, how remote?
Please circle the descriptions that best describe your trip:
Holiday type - Package Self-organised Backpacking
Personal Medical History: Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder:
Do you have any allergies, for example to eggs, antiobiotics, nuts?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint? Yes ( ) No ( ) Do you or any close family members have epilepsy? Yes …………………………… No ( ) Do you have any history or mental illness including depression or anxiety? Yes ( ) No ( ) Have you recently undergone radiotherapy, chemotherapy or steroid treatment: Yes ( ) No ( ) Women only: Are you pregnant or planning pregnancy or breast feeding? Yes: ………………………………………. No ( ) Have you taken out travel insurance? If you have a medical condition, have you informed the insurance company about this? Yes ( ) No ( ) 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/malaria tablets, and if so when? Tetanus ( ) …………………… Polio ( ) …………………. Diphtheria ( ) ……………… Typhoid ( ) …………………. Hepatitis A ( ) …………… Hepatitis B ( ) ……………. Meningitis ( ) ………………. Yellow Fever ( ) ………… Influenza ( ) ………………. Rabies ( ) ……………………. Jap B Enceph ( ) ………… Tick Borne ( ) ……………. Other: …………………………………. Malaria Tablets ( ) ………………………………. 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 consent to the vaccines being given. Signed: Date:
For surgery use only Patient name: ………………………………………………………………………………. Travel risk assessment performed: Yes ( ) No ( ) Travel vaccines recommended for this trip: Disease protection Further information
Travel advice and leaflets given as per travel protocol
Malaria prevention advice and malaria chemoprophylaxis Chloroquine and proguanil ( ) Atovaquone + proguanil (Malarone) ( ) Chloroquine ( ) Mefloquine ( ) Doxycycline ( ) Malaria advice leaflet given ( ) Further information eg: weight of child Signed by: ………………………. Position: ……………………. Date: …….
Para uso diagnóstico in vitro : MycXtra® MycXtra® Kit de extracción de ADN fúngico REF 080-005 Uso previsto El Kit de extracción de ADN fúngico MycXtra® está diseñado para el aislamiento y la purificación del ADN fúngico presente en el lavado broncoalveolar ( bronchoalveolar lavage , BAL), en el esputo y en otras muestras del tracto respiratorio inferior de se
Estarás de acuerdo conmigo en que muchas veces un nombre propio predispone a favor o en contra de una persona desconocida, sólo por el recuerdo que de aquel nombre tenemos de determinada persona que sí conocemos. Un ejemplo claro de ello es, en ocasiones, la disputa de los padres a la hora de elegir el nombre que pondrán a su futuro hijo. El juego cabalístico de las cifras es similar. Y ya,