Patient Travel Questionnaire Please complete this questionnaire and return it as soon as possible.
You may need travel vaccinations depending on the country or countries you intend to visit. Asthe vaccines are not immediately effective, please ask about them as soon as you havebooked, ideally at least 4 weeks before travelling. Please fill in this form and hand it in to thereceptionist. After two working days days you can phone her and make an appointment withthe practice nurse for any injections that are necessary. 9. Are you on any medication or receiving any ongoing medical treatment? Please Address. give details. Date of Birth. Remember to take enough supplies to 1. Which countries do you intend to last until you return home. visit (including brief stopovers) . 10. Are you receiving or have you had radiotherapy within the last 6 months? 2. Will you be staying in hotels or 11. Have you received steroids within under more primitive conditions such the last month? as camping? 12. Have you ever had any of the following 3. Does your journey include: vaccinations, if so when? Coastal areas [ Typhoid [ ] . Inland areas [ Tetanus [ ] . Polio [ ] . 4. Do you plan any safaris, jungle Yellow Fever [ ] . exploring or travel in different terrain? Will you be above 3000m altitude? Hepatitis A [ ] . 13. Have you ever had an adverse reaction to any immunisation? 5. Departure date. 6. Duration of stay abroad N.B. It is important to let us know if you are HIV positive. 7. Are you pregnant or trying to conceive? Your signature. 8. Are you allergic to anything? Smallfield Surgery Travel Information QuestionnaireTravel Vaccinations Always refer to green book if in doubt General contraindications; Pregnancy or trying to conceive
I confirm that I have discussed thecontraindications to vaccination with
Acute illness History of reaction to preceding doses HIV - see green book Contraindications to live vaccine: Pregnancy High dose steroids Immunosuppressive therapy Malignancy Impaired immunity Within 3 months of Gamma-globulin except Yellow fever HIV Anaphylactic reaction to eggs (MMR, Influenza and Yellow Fever) Within 3 months of BCG or 3 weeks of Yellow Fever. Given by: Cost/paid previous previous Diptheria Meningitis Japanese Encephalitis Yellow Fever Any Others Chemotherapy against Malaria: Tick as appropriate: Mefloquine (Larium) Other Chemotherapy Proguanil None necessary Chloroquine Larium contraindicated if history of severe psychiatric disorder or convulsions or pregnancy. Paludrine contraindicated in severe renal failure. Nevaquine contraindicated in pregnancy. Preventative advice 1: Avoiding mosquito bites. 2: Continue chemoprophylaxis for 4 weeks after return. 3: Avoid contaminated food and water. 4: AIDS (Travel packs). 5: Rabies. 6: Sunburn. 7: Altitude sickness if sleeping above 3000 metres. Smallfield Surgery Travel Information Questionnaire
OPINION 15 Monday will mark the 37th anniversary of the imposition of “inter-nal” Emergency, on June 25, 1975, with President Fakhruddin AliAhmed signing the proclamation late at night, even before it hadCabinet approval. An important vignette about those days hascome out, in a booklet written by N Vaghul to honour the memory of R KTalwar, the trail-blazing chairman of State Bank of
Enantioselective Synthesis of a-Hydroxy Ketones via Benzaldehyde Lyase-Catalyzed CÀC Bond Formation ReactionAyhan S. Demir,a,* ÷zge SÀesÀenoglu,a Elif Eren,a Birsu Hosrik,a Martina Pohl,b,dElena Janzen,b Doris Kolter,c Ralf Feldmann,c Pascal D¸nkelmann,c Michael M¸llerc,*Department of Chemistry, Middle East Technical University, 06531 Ankara, Turkey,Fax: ( 90)-312-2101280, e-mail: asdem