Oughtibridge Surgery TRAVEL QUESTIONNAIRE
Please complete this form up to 12 weeks before you travel and return to reception. The nurse will look at the form and you will be contacted.
Personal details
Date of birth: Male [ ] Female [ ] Easiest contact telephone number E mail Dates of trip Date of Departure Return date or overall length of trip Itinerary and purpose of visit Country to be visited Length of stay Away from medical help at destination, if so, how remote? Please tick as appropriate below to best describe your trip 1. Type of trip 2. Holiday type 3. Accommodation 4. Travelling 5. Staying in area Urban 6. Planned activities Safari
Personal medical history Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions) List any current or repeat medications Do you have any allergies for example to eggs, antibiotics, nuts ? Have you ever had a serious reaction to a vaccine given to you before? Does having an injection make you feel feint? Do you or any close family members have epilepsy? Do you have any history or mental illness including depression or anxiety Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Women only: Are you pregnant or planning pregnancy or breast feeding? Have you taken out travel insurance and if you have a medical condition, informed the insurance company about his? Please write below any further information which may be relevant Vaccination History Have you ever had any of the following vaccinations / malaria tablets and if so when? Tetanus
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. Payment for vaccinations is by cash or cheque. Signed __________________________________________ Date ________ For official use 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
personal hygiene advice Insect bite prevention
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS Chloroquine and proguanil FUTHER INFORMATION
e.g. weight of child Signed by: Position: Date: Now scan this form into the patient’s record on the computer for evidence of best practice
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