Travel Clinic Consent Form

Travel Clinic Consent Form

TRAVEL CLINIC CONSENT FORM

***FOR INTERNAL USE ONLY***
Date Taken / Malaria / Pharmacy Advice [ ] Script Req’d [ ]
Taken By / Appointment / Double [ ] Not Req’d [ ]
Passed to Nurse / Patient Informed / ☐ (By______Date ______)
Passed Back to Reception / Appt Date & Time
Patient EMIS Number / Nurse

Please ring a week after you hand this form in to be informed on whether an appointment is required or not.

FOR THE PATIENT TO COMPLETE
Personal Details
Name / Date of Birth
Contact No. / Male [ ] Female [ ]
Address
Dates of Trip
Date of Departure
Length of Trip
Details about Destination(s)
Country / Location / Length of Stay
1.
2.
3.
Do you plan to travel abroad again in the future? Yes [ ] No [ ]
Please tick as appropriate below to best describe your trip
  1. Type of Trip
/ Business / Pleasure / Other
  1. Holiday Type
/ Package / Self-Organised / Backpacking
Camping / Cruise Ship / Trekking
  1. Accommodation
/ Hotel / Relatives/Family Home / Other
  1. Travelling
/ Alone / With Family/Friend / In a Group
  1. Area
/ Urban / Rural / Altitude
  1. Activities
/ Safari / Adventure / Other
Personal Medical History
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
Are you on any current or repeat medications?
Do you have any allergies?
Have you had any previous reactions to any vaccines?
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, planning a pregnancy or breastfeeding?
Please write any further information which may be relevant
Vaccination History
Have you ever had any of the following vaccinations/malaria tablets and if so when?
Tetanus / Polio / Diphtheria
Typhoid / Hepatitis A / Hepatitis B
Meningitis / Yellow Fever / Influenza
Rabies / Jap B Enceph / Tick Borne
Other
Malaria Tablets
FOR THE NURSE TO COMPLETE
Patient Name
Travel Risk Assessment Performed Yes [ ] No [ ]
Travel Vaccinations Recommended for this Trip
Disease Protection / Yes / No / Patient Declined Vaccine / Vaccine Given / Recorded
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Other
Travel Advice Given as per Travel Protocol Travax [ ] Nathnac [ ]
Food, Water & Personal Hygiene / Travellers’ Diarrhoea / Blood/Bodily Fluid Infection Risks
Insect Bite Prevention / Animal Bites / Accidents
Insurance / Air Travel / Sun & Heat Protection
Websites / Travel Record Card Given / Other
Malaria Prevention Advice and Malaria Chemoprophylaxis
Chloroquine and Proguanil / Atovaquone & Proguanil
Chloroquine / Mefloquine
Doxycycline / Malaria Advice Leaflet Given
Further Information
(Including weight if below 16yrs old)
PATIENT CONSENT
(To be completed at the time of the appointment)
I am well today. 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: ______Date: ______

Updated 150114 SH (shared/shared misc forms/forms/travel form)

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