SHERBOURNE MEDICAL CENTRE

Dr P Ainsworth Dr L Oliver Dr R T Courtenay Dr J Mann Dr S Goulding Dr A Bal

40 Oxford Street, Leamington Spa, CV32 4RA

Tel 01926 333500 Fax 01926 470884

www.sherbournemedicalcentre.co.uk

TRAVEL HEALTH

Dear Patient,

In order to help us provide a high standard of travel health consultations, we require you to complete a pre-travel questionnaire (attached) and bring it along with you to your travel health appointment with the practice nurse.

It is essential that all complex travellers obtain a travel health brief from one of the following information sources:

NHS Direct – Tel: 111

www.fitfortravel.nhs.uk-public

www.masta.org

Please bring the information with you to your travel consultation with the nurse.

It is recommended that this appointment is made at least 4 weeks prior to your departure. If your trip is of a complex nature i.e; visiting 2 or more countries or travelling for longer than 3 weeks, we recommend your appointment is made at least 8 to 12 weeks prior to departure.

The purpose of your initial consultation is to discuss your travel vaccination requirements. You will not necessarily commence your vaccinations at this appointment and may require further appointments in order to complete vaccination schedules.

Some of your travel vaccinations may require payment. Please note if any payments are required for vaccines we can only accept cash or a cheque accompanied by a bank card, payments are to be made on the day you receive your vaccinations.

Thank you for your help with this.

PRACTICE NURSE TEAM

Name: / Date of birth
Male [ ] Female [ ]
Easiest contact telephone number
Email
Dates of trip
Date of departure
Return date or overall length of trip
Details about the destination(s)
Country and location to be visited / Length of stay / Away from medical help at destination, if so, how remote?
1.
2.
3.
Do you plan to travel abroad again in the future?
Please tick as appropriate below to best describe your trip
1. Type of trip / Business / Pleasure / Other
2. Holiday type / Package / Self organised / Backpacking
Camping / Cruise ship / Trekking
3. Accommodation / Hotel / Relatives/family home / Other
4. Travelling / Alone / With family/friends / In a group
5. staying in area which is / Urban / Rural / Altitude
6. planned activities / Safari / Adventure / Other
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 or latex?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
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 breastfeeding?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Please write below any further information that may be relevant
Vaccination history
Have you ever had any of the following vaccinations/ malaria tablets and if so when?
Tetanus / Polio / Diphtheria
Typhoid / Hepatitis A / Hepatitis B
Meningitis / Yellow Fever / Influenza
Rabies / Jap B Enceph / Tick Borne
Other:
Malaria Tablets

For discussion when risk assessment is performed with 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.

Signed: ______Date: ______

FOR OFFICE USE
Patient Name:
Travel risk assessment performed Yes [ ] No [ ]
Travel vaccines recommended for this trip
Have you ever had any of the following vaccinations/ malaria tablets and if so when?
Disease protection / Yes / No / Patient declined vaccine / Vaccine name, dose and & schedule for PSD
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
other
Travel advice and leaflets given as per travel protocol
Food, water and personal hygiene advice / Travellers’ diarrhoea / Blood and bodily fluid infection risks e.g. Hepatitis B
Insect bite prevention / Animal bites / Accidents
Insurance / Air travel / Sun and heat protection
Websites / SMS vaccines reminder service set up
Travel record card supplied / other
Malaria prevention advice and malaria chemoprophylaxis
Chloroquine and proguanil / Atovaquone + proguanil
Chloroquine / Mefloquine
Doxycycline / Malaria advice leaflet given
Further information
e.g. weight of child
Authorisation for Patient Specific Direction (PSD) Use
Name______Signature ______Date ______

SHERBOURNE MEDICAL CENTRE

Dr P Ainsworth Dr L Oliver Dr R T Courtenay Dr J Mann Dr S Goulding Dr A Bal

40 Oxford Street, Leamington Spa, CV32 4RA

Tel 01926 333500 Fax 01926 470884

www.sherbournemedicalcentre.co.uk

TRAVEL VACCINATIONS

2016

Please note: All doses must be paid for at the first visit, prior to your appointment

Travel Consultation / Name / Charge
Hepatitis B (3 doses) / Engerix B / £35.00 per dose
Yellow Fever / Starmaril / £65.00
Rabies / £20.00 (private prescription & administering)
Japanese Encephalitis
Tick Bourne Encephalitis
ACWY Vaccinations
Hepatitis B (Paediatric)
Private prescription for Travel (including malaria tablets) / £15.00
Duplicate Yellow Fever Certificate / £16.00
Holiday Cancellation / Short Certificate / £28.00
Holiday Cancellation / Report / £40.00
Fitness to Travel / Short Certificate / £25.00
Fitness to travel / Report / £40.00

OTHER PRIVATE SERVICES

Type / Charge Per Episode
Private Blood Test / £20.00 (lab fees will then apply)
Paternity Blood Tests / £20.00 (lab fees will then apply)
ECG Recording / £40.00
Spirometry Test and Report / £33.00
Audiogram and Report / £32.00

Private Travel Vaccination Schedule appointment requirements

Scheduled days / Japanese Encephaltis / Rabies / Hepatitis B
Aged 18+ / Hepatitis B
Age 11-15 yrs
(20mcg/ml)
Day 0 / Dose 1 / Dose 1 / Dose 1 / Dose 1
Day 7 / Dose 2 (rapid schedule only) / Dose 2 / Dose 2
Day 14
Day 21 / Dose 3 (if short of time pre trip) / Dose 3
Day 28 / Dose 2 (normal schedule only) / Dose 3 (normal schedule)
6 months / Dose 2
12 months / Dose 4

·  All vaccine schedules require a PSD requesting prior to appointment with the nurse

·  All the above vaccines can be given together if two or more vaccines are due on the same day