Linen Court Surgery

Pre-Travel Form

If you are travelling abroad you may need vaccinations. Please fill in the first 3 pages of this form and then return the completed form to the surgery at least 6-8 weeks before you travel. Make sure you leave a daytime contact number.

If your travel is for a short holiday or business trip to eg Turkey, Egypt, Mexico or North Africa then this should be fairly straightforward. A member of staff will be in contact to let you know the arrangements for you to collect a prescription for any vaccinations required. You should then make an appointment for the Treatment Room to have these vaccinations given.

If your travel is to a tropical country with a risk of malaria, or if you will be backpacking or living and working in basic circumstances then your pre-travel health requirements may be more complex. In this case one of the doctors or nurses from the surgery will be in contact to discuss these arrangements.

Name ...... Dob ………………………

Address………………………………………………………………………………………………………………………………

Daytime Tel No ……………………………………….. Mobile No ……………………………………………

Date of travel
Date of return

Destination

Give details of the countries you will be visiting, in the correct order, including any country you may just be passing through

Country to be visited
Area/Region / Length of stay / Type of accommodation / Travelling to remote areas or away from medical help
1.
2.
3.
4.
5.
6.
7.
8.

Type of travel: Circle which activity best describes the purpose of your trip

Reason for travel: Business Leisure Charity

Type of travel: Package Cruising

Self organised Camping Backpacking

Are you travelling with: Family Group Alone

Planned activities: Living/working Safari

in remote areas

Voluntary work

Mountain trekking

Personal Medical History:

Give details of any conditions which may affect your travel plans

Do you have any current or past medical conditions of any note?
eg. pregnancy, diabetes, heart or lung conditions, epilepsy, immunosuppression, cancer,
HIV
List any medication that you are taking

Do you have or have you ever had any of the following?:

Allergies (eg eggs, antibiotics)
A previous reaction to any vaccine
Recent surgery
Treatment with steroids, chemotherapy or radiotherapy
Epilespy
Anxiety, depression or mental illness

Vaccination History: Please tick any travel vaccine that you have previously been given stating when

Travel Vaccine / Date(s) given if known
Tetanus/Polio/Diphtheria (in last 10 yrs)
Hepatitis A
Hepatitis B
Typhoid
Meningitis (for travel)
Rabies
Yellow Fever
Japanese B Encephalitis
Tick-borne Encephalitis

Malaria: List the name of any malaria tablets that you have previously taken, if you cannot remember the name of the tablet it may be useful to list the country visited

1. 
2. 
3. 

Please give any further information that you feel may be relevant

Remember:

□ Allow plenty of time for pre-travel arrangements. Leave this form back to the surgery
at least 6-8 weeks before you travel
□ A dental check-up before you travel may prevent problems while you are away
□ Take out adequate insurance for your destination and activities. A European
Health Insurance Card (EHIC) entitles you to free or reduced rate medical care
in most EU countries. You can apply for one free of charge online(www.dh.gov.uk),
by phone (0845 606 2030), or by post using a form from the Post Office
□ Find out about the place you are travelling
The following websites are very helpful
www.nidirect.gov.uk/get-the-latest-foreign-travel-advice
www.fitfortravel.nhs.uk
www.travelhealthpro.org.uk

Return this form to the surgery and we will contact you to make arrangements

SURGERY USE ONLY Date

Doctor/Nurse completing this assessment…………………………………………………….. / /

Comments on proposed travel

Vaccines recommended for this trip

Number of doses schedule
required or comments
Hepatitis A
Typhoid
Tetanus/polio/diphtheria
Hepatitis B
Rabies
Meningitis ACWY
Japanese Encephalitis
Tick-borne Encephalitis
Yellow fever
Cholera

Is Malaria Chemoprophylaxis required Y/N (refer to TRAVAX if necessary)

Chloroquine and proguanil
Chloroquine
Atovaquone + proguanil (Malarone)
Doxycycline
Mefloquine (Lariam)
Malaria Advice sheet given
Printout on chosen antimalarial given

Patient contacted date: / / By whom:

Treatment Room

Vaccination schedule

Interval
between
Vaccine / Date
given / Vaccine / Sticker / Given
by
Travel vaccine record supplied

Computer codes

Foreign Travel NOS - when patient leaves in form
Travel advice - when attends Treatment Room

Patient consent

I have received and understood the advice given to me concerning

o  Travel vaccination requirements

o  Anti-malarial prophylaxis

o  General preventative measures

For myself/my child and consent to the administration of the recommended vaccination

Signature ………………………………………………………………………..


Date ………………………………………………………………………………..