ST MARTIN’S GATE SURGERY

Turnpike House Medical Centre, 37 Newtown Road, Worcester WR5 1EZ

Tel. 01905 363351

PART A: To be completed separately for all individual travellers

Past Medical history. Please answer yes / no to following questions & give further information at end if appropriate / Yes/No
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
Do you take any medication, if yes please list below.
Do you have any allergies? Especially. eggs, antibiotics, nuts, latex, mercury or thimerosal or anything else If yes please list them below.
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 or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only: Are you pregnant or planning pregnancy in next 3 months or breast feeding?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Please write below any further information which may be relevant.

PATIENT NAME: ______D.O.B: ______

PLEASE BRING TO YOUR APPOINTMENT ANY INFORMATION REGARDING PREVIOUS VACCINATIONS

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. I am aware there may be a charge for some vaccinations and realise that I have to pay in advance for these.

Signed ______Date ______

PART B OF THE FORM WILL BE COMPLETED BY THE NURSE DURING YOUR CONSULTATION

PART B

PATIENT NAME: ______D.O.B: ______

Date/Time of appointment:- ______

(FOR NURSE TO COMPLETE AT APPOINTMENT)

FOLLOWING TO BE COMPLETED BY NURSING STAFF ONLY
Travel risk assessment performed Yes [ ] No [ ]
Primary Immunisation Complete Yes [ ] No [ ]
Future Travel discussed Yes [ ] No [ ]
Disease protection / Yes / No / Advised for trip? / Details vaccinations given
And boosters needed
Hepatitis A - FREE
Typhoid FREE
Revaxis (DTP) FREE
Meningitis ACWY
£40.00
Rabies
£100 (3 injections)
Japanese B Encephalitis
£70.00 (2 injections)
Hep B Adult
£135 (3 injections)
Hep B Adult Booster
£30.00
Hep B for Children
£126.00 (3 injections)
Hep B for Children Booster
£27.00
Malarone (Malaria tablets)
Private Px £10.00 + additional cost at pharmacy

PATIENT TO KEEP THIS PAGE

Useful Websites for Travel and Vaccine Information

Travel

www.fitfortravel.nhs.uk

www.fco.gov.uk/travel

www.travelhealthpro.org.uk

https://travelaware.campaign.gov.uk/

Foreign and commonwealth Office (FCO) Assistance

If something goes wrong while you are abroad, you can contact the FCO Consular Assistance Team in London on: +44 20 7008 1500

To find your nearest embassy

Visit http://www.fco.gov.uk/en/travel-and-living-abroad/find-an-embassy/

General FCO Travel Advice:

Visit: http://www.fco.gov.uk/en/

Tel: 0845 850 2829 (24 hours a day)

Email:

Zika virus information:

https://www.gov.uk/government/collections/zika-virus-zikv-clinical-and-travel-guidance

http://travelhealthpro.org.uk/news/4/zika-virus--update-and-advice-for-travellers-including-pregnant-women-and-those-planning-pregnancy