Microsoft word - travel clinic questionnaire - feb 2014.rtf
HAY-ON-WYE & TALGARTH MEDICAL PRACTICE TRAVEL HEALTH QUESTIONNAIRE Please complete this questionnaire and return it to the Medical Centre at least three weeks prior to your Clinic Appointment TRAVEL IMMUNISATIONS SHOULD BE GIVEN AT LEAST 4 WEEKS BEFORE TRAVEL NAME: ……………………………………………………… DOB ……………. ADDRESS: ……………………………………………………………………. ……………………………………………………………………………………………… TELEPHONE NUMBER: ……………………………………………………………. 1. Departure date: ____________________ 2. Length of stay: _____________ 3. Direct flight : YES/NO 4. Which countries do you intend to visit and the duration in each? Please also state region of Please bring any additional paperwork e.g. recommended by travel agents/previous travel vaccination records 5. Will your journey take you to the: 6. Will you be staying in:
Hotels __ Relatives’ Islands __ Accommodation 7. Are you travelling with:
Partner __ 8. Are you going on:
An organized package tour Organising it yourself Taking a backpacking holiday 9. Is your holiday for: Pleasure Business A period of voluntary service (in a remote area) __ 10. Will you be on safari? YES/NO If yes please give details: _______________________________________
11. Will you be in areas where medical help is non-existent (even for a short period)? YES/NO If yes please give details: _______________________________________ 12. Are you suffering from any minor ailments? YES/NO If yes please give details: _______________________________________ 13. Do you have any long term medical conditions? YES/NO If yes please give details: _______________________________________ 14. Do you have a history of epilepsy? YES/NO If yes please give details: _______________________________________ 15. Do you have any history of depression? YES/NO If yes please give details: _______________________________________ 16. Have you ever had your spleen removed: YES/NO 17. Have you ever suffered a bad reaction to any type of vaccine? YES/NO If yes please give details: _______________________________________ 18. Do you have any allergies e.g. eggs? YES/NO If yes please give details: _______________________________________ 19. Are you currently on any medication including the oral contraceptive pill? YES/NO If yes pleases give details_______________________________________ 20. Are you pregnant, breast feeding or planning a pregnancy? YES/NO If yes please give details: _______________________________________ 22. Have you previously had any vaccinations? YES/NO If yes please give details: PREVIOUS VACCINES Please note that there are some vaccines required for travel in certain countries which are not provided by the NHS, therefore patients will be charged for these vaccines DECLARATION BY PATIENT: I agree that the information I have supplied is correct Signed: ……………………………………………………. Date: …………………… Patient Name: _________________________________ DOB: _____________ Patient Number: _______________________ Recommended Date of First Appointment: ____________________________
Vaccine Recommended:
Hepatitis
* Not given at the Medical Centre – if required, you will be re-directed to an appropriate facility Malaria: Chloroquine
Record of Other Advice:
Health advice for travelers leaflet YES/NO
COMMENTS/NOTES:
GP : Nurse : ………………………………………………………. Date : ……….……………………………………………….
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