ALNWICK MEDICAL GROUP – FOREIGN TRAVEL QUESTIONNAIRE

Name: / Date of Birth:
Male [ ] Female [ ]
Email: / Home Number:
Mobile Number:
PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTION BELOW
Date of Departure: / Date of Return:
Countries to be visited: / Length of stay: / How far from medical facilities? (e.g. urban, rural, very remote)
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2
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Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
TYPE OF TRAVEL AND PURPOSE OF TRIP – PLEASE TICK ALL THAT APPLY
Package holiday [ ]
Organised adventure holiday [ ]
Self-organised [ ]
Visiting family/friends [ ]
Climbing mountains [ ] / Safari [ ]
Cruise [ ]
Backpacking [ ]
Expedition [ ]
Diving [ ] / Business [ ]
Voluntary work [ ]
Aid Worker [ ]
Migration [ ]
Expedition [ ]
Other (Please specify) [ ]
PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY
YES / NO / DETAILS
Are you fit and well today?
Do you have any allergies?
Severe reaction to a vaccine before
Tendency to faint with injections
Any surgical operations in the past
Recent chemotherapy/radiotherapy/organ transplant
Anaemia
Bleeding/clotting disorder? (previous DVT)
Heart disease e.g. angina, high blood pressure
Diabetes
Disability
Epilepsy/seizure
HIV/AIDS
Gastrointestinal (stomach) complaints
Liver and or kidney problems
Immune system condition
Mental Health issues
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) condition
Spleen problems
Any other condition?
WOMEN ONLY
Are you currently pregnant?
Are you breast feeding?
Are you planning pregnancy whilst away?
Are you currently taking any medication? (including prescribed, purchased or contraception)
PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST
Tetanus [ ]
BCG [ ]
Typhoid [ ]
Meningitis [ ]
Japanese B encephalitis [ ] / Polio [ ]
Cholera [ ]
Hepatitis A [ ]
Yellow Fever [ ]
Tick borne encephalitis [ ] / Diphtheria [ ]
MMR [ ]
Hepatitis B [ ]
Rabies [ ]
Other [ ]
Anti-malarial tablets and any adverse effects:
ANY ADDITIONAL INFORMATION

Thank you for completing this form. Please return to Alnwick Medical Group. Providing the information in advance, should enable us to make the most efficient use of your consultation time.

To be completed by the Nurse

Patient Name: / DOB:
Travel risk assessment performed Yes [ ] No [ ]
Telephone consultation Yes [ ] No [ ]
Appointment given/offered Yes [ ] No [ ]

Travel vaccinations recommended for this trip

Disease protection / Yes / No / Further information
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Other

Malaria prevention advice and malaria chemoprophylaxis

Chloroquine and proguanil / Atovaquone + proguanil (Malarone
Chloroquine / Mefloquine
Doxycycline / GP appointment advised
Low risk medication not necessary
Travel advice and leaflets given as per travel protocol Yes [ ] No [ ]
Travel record card supplied Yes [ ] No [ ]
Form sent for scanning Yes [ ] No [ ]
Signed by:
Practice Nurse: / Date: