East Norwich Medical Partnership

East Norwich Medical Partnership

Travel Enquiry Questionnaire

Full Name: / Date of Birth
Male/Female* / Contact Telephone Number:

*Please delete as necessary

Travel Details

Countries & Areas Visiting
Departure Date
Length of Stay
Away from Medical help
If so how remote?

Please tick below as appropriate to best describe the trip:

Type of Trip / Business / Pleasure / Other
Holiday Type / Package / Self-Organised / Backpacking
Camping / Cruise Ship / Trekking
Accommodation / Hotel / Relative/Family Home / Other
Travelling / Alone / With Family/Friend / In a Group
Staying in area which is / Urban / Rural / Altitude
Planned Activities / Safari / Adventure / Other

Personal Medical History

Do you have any recent or past medical history of note (including diabetes, heart or lung conditions / Yes/No*
List any current or repeat medications:
Do you have any allergies for example eggs, antibiotics, nuts? / Yes/No*
Have you ever had a serious reaction to a vaccine given before? / Yes/No*
Does having an injection make you feel faint? / Yes/No*
Do you or any close family members have epilepsy? / Yes/No*
Do you have any history of mental illness including depression or anxiety? / Yes/No*
Have you recently undergone radiotherapy, chemotherapy or steroid treatment? / Yes/No*
Women Only: Are you pregnant or planning pregnancy or breast feeding? / Yes/No*
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this? / Yes/No*
Please include any further information which may be relevant.

*Please delete as necessary

Vaccination History

Have you ever had any of the following Vaccinations/Malaria Tablets, and if so when?

Tetanus / Polio / Diphtheria / Malaria Tablets
Typhoid / Hepatitis A / Hepatitis A / Tick Borne
Meningitis / Yellow Fever / Influenza / Jap B Enceph
Rabies / Other:

Patient Signature: Date:

Full Name: / Date of Birth
Male/Female* / Contact Telephone Number:

Appointment Information

Nurse:
Appointment Length Required:
Appointment Date / Week Commencing:
Reception:
Date & Time of Appointment
Receptionist Name

Travel vaccines recommended for this trip:

Disease Projection / Required / Further Information
Hepatitis A / Yes / No*
Hepatitis B / Yes / No*
Typhoid / Yes / No*
Cholera / Yes / No*
Tetanus / Yes / No*
Diphtheria / Yes / No*
Polio / Yes / No*
Meningitis / Yes / No*
Yellow Fever / Yes / No*
Rabies / Yes / No*
Japanese B Encephalitis / Yes / No*
Other

*Please delete as necessary

Travel Leaflets

Travel Record Card / Yes / No* / Travax Sheet / Yes / No*

*Please delete as necessary

Malaria Prevention Advice and Malaria Chemoprophylaxis

Chloroquine and Proguanil / Atovaquone and Proguanil (Malarone)
Chloroquine / Mefloquine
Doxycycline / Malaria Advice Leaflet
Nurse Preparing Information
Nurse Giving Vaccinations

Patient Statement

I have no reason to think I may 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.

Signature: Date: