Please complete page 1 & 2 prior to your travel appointment and bring all 3 pages to the Travel Nurse. Personal details Name: _____________________________________________________________________________________________________ Date of Birth:
_____________________________________________________________________________________________________ Easiest contact telephone number:
_____________________________________________________________________________________________________
E.mail: _____________________________________________________________________________________________________ GP name and address if not enrolled at this medical practice: _____________________________________________________________________________________________________ Date of Departure…………………………………………… Overall length of trip……………………………….
Itinerary and purpose of visit
Country to be visited
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1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________ 4. _____________________________________________________________________________________________________ 5. _____________________________________________________________________________________________________ 6. _____________________________________________________________________________________________________ Please circle the descriptions that best describe your trip 1.
_____________________________________________________________________________________________________ 2.
_____________________________________________________________________________________________________ 3.
Other……………………………….
_____________________________________________________________________________________________________ 4.
_____________________________________________________________________________________________________ 5.
_____________________________________________________________________________________________________ 6.
_____________________________________________________________________________________________________ Personal medical history Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder. _____________________________________________________________________________________________________ List any current or repeat medications. _____________________________________________________________________________________________________ Do you have any allergies, for example to eggs, antibiotics, nuts? Patient Name: Date of Birth:
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 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? 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. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Vaccination history
Have you ever had any of the following vaccinations/malaria tablets, and if so, when?
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_____________________________________________________________________________________________________ Other _____________________________________________________________________________________________________ Malaria tablets _____________________________________________________________________________________________________ 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:
For official use
Travel risk assessment performed Yes [ ] No [ ] Authorisation for Nurse to administer vaccination.
Signed…………………………………………………………………….
_____________________________________________________________________________________________________ Travel vaccines recommended for this trip Disease protection Recommended Further information
Hepatitis A _____________________________________________________________________________________________________ Hepatitis B _____________________________________________________________________________________________________ Typhoid _____________________________________________________________________________________________________ Cholera _____________________________________________________________________________________________________ Tetanus/Diptheria _____________________________________________________________________________________________________ MMR _____________________________________________________________________________________________________ Polio _____________________________________________________________________________________________________ Meningitis ACWY _____________________________________________________________________________________________________ Yellow Fever _____________________________________________________________________________________________________ Rabies _____________________________________________________________________________________________________ Japanese B Encephalitis _____________________________________________________________________________________________________
Other Travel Record card supplied _____________________________________________________________________________________________________ Travel advice and/or leaflets given as per travel protocol
Food, water and personal hygiene advice Travellers diarrhoea Hepatitis B, C and HIV _____________________________________________________________________________________________________
Insect bite prevention Rabies Accidents Insurance Air travel _____________________________________________________________________________________________________
Sun and heat protection Hajj travel Yellow Fever Blood borne virus _____________________________________________________________________________________________________
Global Traveller Checklist Malaria Altitude sickness Cruise ship travel _____________________________________________________________________________________________________
_____________________________________________________________________________________________________ Malaria prevention advice and malaria chemoprophylaxis
Atovaquone + proguanil (Malarone) Chloroquine Mefloquine Doxycycline _____________________________________________________________________________________________________ Further information e.g. weight of child Signed by:
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