Patient to Complete Below
FOREIGN TRAVEL
DATE RECEIVED BY RECEPTIONPATIENT TO COMPLETE BELOW
Travelling dates:-· We like to have 8 weeks notice prior to your trip (longer if complicated itinerary). Please complete this form and call reception a week later.
· Between 3 & 8 weeks, complete this form and book a 10 min phone consultation 4/5 days later with a practice nurse to discuss your requirement. Appointments will only be fitted in if possible.
· Less than 3 weeks DO NOT complete this form as you will need to go to a travel clinic for your consultation. Please ask reception to print details of previous vaccines to take with you.
Please bring any record of previous immunisations. There may be a charge for some services.
Full Name:-
Date of Birth:-
Daytime Telephone Number:-
Country visiting / Exact location or region / City or Rural / Length of stay
Type of holiday / Hotel / Backpacking / Visiting family/friend / Safari / Cruise / Other
Date of departure:- / Date of return:-
YES / NO / DETAILS
Any allergies including food, latex, medication
Severe reaction to vaccine before
Tendency to faint with injections
Any surgical operations in the past, including e.g. your spleen or thymus gland removed
Recent chemotherapy/radiotherapy/organ transplant
Anaemia
Bleeding/clotting disorders (including history of DVT
Heart disease (e.g angina, high blood pressure)
Diabetes
Disability
Epilepsy/Seizures
Gastrointestinal (stomach) complaints
Liver & Kidney problems
HIV/Aids
Immune system condition
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions?
WOMEN ONLY
Are you pregnant?
Are you breastfeeding
Are you planning pregnancy while away
(to be completed by Practice nurse)
Length of Appointment time / minutes / (to be completed by Practice nurse)
form completed by / date
(to be completed by RECEPTION)
Appointment Booked / date / time / Practice nurse
Message for patient
FOR HEALTH PROFESSIONAL USE ONLY
Patient Name
DOB:
Childhood immunisation history checked:
Additional information:
National database consulted for travel vaccines recommended for this trip and malaria chemoprophylaxis (if required): NaTHNaC: TRAVAX: Other:
Disease protection advised / YES / Prev dose / Disease protection advised / YES / Prev dose / Malaria Chemoprophylaxis recommendation / YES
Cholera / Influenza / Atovaquone/proguanil
Dip/tetanus/polio / Meningitis ACWY / Chloroquine only
Hepatitis A / MMR / Chloroquine and proguanil
Hepatitis B / Rabies / Doxycycline
Hepatitis A+B / TBE / Proguanil only
Hepatitis A + Typhoid / Typhoid
Japanese Encephalitis / Yellow fever / Emergency standby
Other / Weight of child:
Vaccine and General Travel Advice required/provided
Patient consent for vaccination obtained: verbal written
Post vaccination advice given: verbal written
General travel advice leaflet given Yes No
Items ticked below indicate topics discussed within the consultation
Food and water borne risks
Travellers’ diarrhoea advice
Sexual health & blood borne virus risk
Rabies specific advice
Mosquito bite prevention
Malaria prevention advice
Source of advice used for further information : NaTHNaC TRAVAX Other
OR no additional specialised advice given □
NOTES