Borras

Please complete this form prior to your travel appointment and return to reception.
Easiest, contact telephone number:…………………. E-mail: ………………………… Date of departure: .Return date or overall length of trip: .
Away from medical help at destination?If so, how remote? Please circle the descriptions that best describe your trip Have you ever had any of the following vaccinations/malaria tablets, and if so when? 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.
Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder.
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Do you have any al ergies for example to eggs, antibiotics, nuts? If yes give details ……………………………………………………………………………………… Have you ever had a serious reaction to a vaccine given to you before? If yes give details: …………………………………………………………………………………… Have you recently undergone radiotherapy, chemotherapy or steroid treatment? YES Please give details …………………………………………………………………………………… Women only: Are you pregnant or planning pregnancy or breast feeding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .….………………………………………….
Have you taken out travel insurance? If you have a medical condition, have you informed the insurance company about this? Please give any further information that may be relevant, including any future travel plans.
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Travel vaccines recommended for this trip Hepatitis A___________________________________________________________________________________Hepatitis B___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________Diphtheria ___________________________________________________________________________________Polio___________________________________________________________________________________Meningitis ACWY___________________________________________________________________________________ ___________________________________________________________________________________Rabies___________________________________________________________________________________Japanese B Encephalitis___________________________________________________________________________________ ___________________________________________________________________________________ T r a vel advice and leaflets given as per travel protocol Malaria prevention advice and malaria chemoprophylaxis Further information eg: weight of child .
Signed by:…………………………… Position:…………………………….

Source: http://www.borrasparksurgery.co.uk/travel.pdf