MEDICAL HISTORY Please Tick If You Have Ever Suffered from Any of the Following Problems

SOUTHVIEW MEDICAL PRACTICE
Travel Vaccination Form
Please complete ALL SECTIONS in BLOCK CAPITALS
IMPORTANT – Please read the following notes before completing the form
·  Please allow at least 5 working days for your vaccination programme to be prepared and priced if applicable. The final cost may differ as during your consultation there may be a need to alter the vaccinations suggested to suit your travel arrangements.
·  Your travel form will be looked at on a Wednesday afternoon. Please aim to hand it in by a Wednesday morning.
·  The surgery will contact you to make the necessary appointment.
TRAVEL CLINIC TIMES / Lead Travel Nurse
Thursday pm at Southview Surgery / Jane Howlett
Full Name and Address
Date of Birth
Contact Telephone Number:
Email
ALL PLACES TO BE VISITED-Continue on separate sheet of paper if necessary
Rural Area / Dates / (Office Use only)
(please tick) / Malaria
Country / Town/City / Yes / No / From / To
TICK ALL THAT APPLY
Accommodation / Hotel Family Home Tents Hostels Ship
Type of Trip / Business Pleasure Other [specify]
Holiday Type / Package Self-organised Backpacking
TrekkingCamping Cruise

MEDICAL HISTORY Please tick if you have ever suffered from any of the following problems

Anxiety, depression or stress / High Blood Pressure / Mental Illness
Diabetes / Heart, lung or kidney disease / Stroke
Epilepsy / Hepatitis or liver disease / Tuberculosis
CURRENT MEDICATION (Including contraceptive pills and over the counter treatment)
ALLERGIES(e.g. drugs, eggs, nuts)

FURTHER INFORMATION

Have you ever had a serious reaction to a vaccine given to you before? / Yes No
Does having an injection make you feel faint? / Yes No
Have you recently undergone radiotherapy, chemotherapy or steroid treatment? / Yes No
Do any of your close family have epilepsy? / Yes No
Are you pregnant or planning pregnancy, or breast feeding? [state which] / Yes No
Have you taken out travel insurance? / Yes No
If you have a medical condition, have you informed the insurance company? / Yes No
Have you ever taken anti-malarial tablets before? / Yes No
PLEASE NOTE
·  Please bring your itinerary if you have one
·  Please bring with you any record you have of your previous vaccinations
·  Your travel clinic appointment is free. However please be aware that there are charges for some travel vaccines
·  All vaccines that need a payment must be paid before ordering, which will be discussed at your first appointment. You will then be contacted to arrange further appropriate appointment(s)
All necessary charges must be paid by CHEQUE supported with cheque guarantee card or CASH. SORRY WE CANNOT ACCEPT CARD PAYMENTS
Signature: Date:

OFFICE USE ONLY

Date Travel Form was returned to the practice.
Date Nurse Howlett viewed Travel Form

Patient Requires:-

20 minute travel appointment with Nurse Howlett

10 minute travel appointment with Nurse Howlett

Patient requires the following vaccinations to be administered:

Vaccines
Hep A / Hep B
Typhoid / Rabies
DTP / Japanese B Encephalitis
Yellow Fever
Men ACWY

TOTAL AMOUNT OF VACCINES £ ______

Antimalarials
Required / Country/Area (notes)
Cholorquine
Proguanil
Atovaquone/Proguanil
Doxycycline
Mefloquine
Repellents/anti bite measures