Microsoft word - travelassessmentform_final_march2013.docx
1. BEFORE YOUR TRAVEL CONSULTATION with us you must complete as
much of SECTION A of this form as you can. Section B is for our use and will be completed by your travel nurse. Please print out all three pages. 2. PLEASE BRING any vaccination history you may have to any vaccination
appointments you arrange. e.g. from your GP.
3. DO NOT eat or drink for 1 hour before vaccination appointments in case 4. BE AWARE that some vaccination programmes must be started 6-8 weeks By booking any appointments such as your consultation or vaccination appointments you are committing to our appointment prices. You will be liable for full charges if you;
Cancel or rearrange your appointment(s) within 2 working days of the
Attend but are unable, or choose not to have your vaccinations. Please not you will not be liable for any pharmacy charges should you choose not to proceed, cancel or rearrange as these can be used for other clients. Further information can be found at www.workingwell2gether.nhs.uk
Page 1 of 3 SECTION A: Please complete this page. Personal Details Full Name:
Your Itinerary and purpose of visit Dates of trip departure:
Away from medical help at destination? If so, how remote?
Please tick below as appropriate to best describe your trip 1. Type of Trip 2. Holiday 3. Accommodation 4. Travelling 5. Staying in ___ area 6. Planned activities
Personal Medical History (Please use another sheet if necessary) 1. Do you have any recent or past medical history of note?
(including diabetes, heart or lung conditions)? 2. List any current or repeat medications (or bring list with you): 3. Do you have any allergies for example to eggs, antibiotics, nuts? O YES 4. Have you ever had a serious reaction to a vaccine given to you
before? 5. Does having an injection make you feel faint? 6. Do you have any problems swallowing? 7. Do you or any close family members have epilepsy? 8. Do you have any history or mental illness including depression
or anxiety? 9. Do you have any kidney or liver problems? 10. Have you recently undergone radiotherapy, chemotherapy or
steroid treatment? 11.Women Only: Are you pregnant or planning pregnancy or
breastfeeding? 12. Have you taken out travel insurance? If so, and if you have a medical condition have you informed your insurance company about this? 13. Please add any further information which may be relevant (e.g. YES answers above)? Vaccination History Have you ever had any of the following vaccinations / malaria tablets and if so when? Diptheria
Page 2 of 3 SECTION B: For Clinician use only. Patient Full Name: Travel risk Assessment Performed: Travel Vaccines recommended for this trip Disease Protection No Further Information Travel Advice and leaflets given as per travel protocol Food water and personal O Travellers’ diarrhoea Malaria prevention advice and malaria chemoprophylaxis Chloroquine and proguanil Further information Practitioner Full Name: Date: DD/MM/YYYY Declaration 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 and the charges outlined on page 1. Patient Signature: Date: DD/MM/YYYY
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