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Microsoft word - travel vaccination questionnaire pdf.doc


TRAVEL VACCINATION QUESTIONNAIRE
Page 1 of 3


Please complete this form prior to your travel appointment and return to reception

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 which
is
6. Planned activities

Marske: Windy Hill Lane, TS11 7BL. Tel : 01642 477133 Saltburn: 2 Windsor Rd, TS12 1BH. Tel : 01287 622393
TRAVEL VACCINATION QUESTIONNAIRE
Page 2 of 3

Personal medical history
Do you have any recent or past medical history of note? (Including diabetes, heart or lung conditions
or Spleen Removal)
Are you taking any medication?
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?
Do you or any close family members have epilepsy?
Do you have any history of 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 Including Childhood and School Vaccines
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. Signed __________________________________________ Date ________ Marske: Windy Hill Lane, TS11 7BL. Tel : 01642 477133 Saltburn: 2 Windsor Rd, TS12 1BH. Tel : 01287 622393
TRAVEL VACCINATION QUESTIONNAIRE
Page 3 of 3
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

MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
FUTHER INFORMATION
e.g. weight of child

Signed by: Position: Date:
I give consent to the administration of the vaccines recommended above
Patient Name: Signature

PLEASE NOTE IT IS THE PATIENTS RESPONSIBILITY TO CONTACT THE SURGERY
AFTER 5 WORKING DAYS FOR DETAILS OF ANY IMMUNISATIONS OR MEDICATIONS
REQUIRED.: Tel: 01642 477133 or 01287 622393
Marske: Windy Hill Lane, TS11 7BL. Tel : 01642 477133 Saltburn: 2 Windsor Rd, TS12 1BH. Tel : 01287 622393

Source: http://www.zetlandmedicalpractice.co.uk/downloads/Travel%20vaccination%20questionnaire%20PDF.pdf

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