- King Edwards Medical Group
Transcription
- King Edwards Medical Group
King Edward’s Medical Group www.kingedwardsmedicalgroup.com TRAVEL ASSESSMENT FORM Please complete this form prior to your travel appointment and return to our nurses/ reception. The form will be assessed and then our nurses will advise you. Please fill this at least 8 weeks prior to your departure. PERSONAL INFORMATION First Name: Date of Birth: Surname: Male _ Female _ Prefered contact telephone number: DATES OF TRIP: Date of departure: Return date or overall length of trip: ITINERARY Country to be visited Length of stay Will you be away from medical help at destination, if so, how remote? PURPOSE OF TRIP (For each section, please tick as appropriate how best to describe your trip) Type of trip Holiday type Accommodation Staying in area which is Buisness Pleasure Package Self organised Medical Other Backpacking Camping Trekking Cruise Ship Safari Adventure Other Hotel Relatives/ Family Other Urban Rural Altitude PERSONAL MEDICAL INFORMATION 1|Page Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions) Yes _ No _ List any current medication not prescribed by surgery or herbal remedies routinely Taken Do you have any allergies, for example to eggs, antibiotics or nuts? Yes _ No _ Have you ever had a serious reaction to a vaccine given to you before? Yes _ No _ Does having an injection make you feel faint? 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: are you pregnant, 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 write below further information which may be relevant VACCINATION HISTORY (Please provide dates of any immunisations received outside the surgery for the diseases listed below) Tetanus Meningitis Polio Yellow Fever Diptheria Influenza Typhoid Rabies Hepatitis A Jap B Enceph Hepatitis B Tick Borne Other Malaria Tablets FOR COMPLETION PRIOR TO VACCINATION DURING 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 Date For official use: 2|Page Travel risk assessment performed Yes _ No _ TRAVEL VACCINES RECOMMENDED FOR THIS TRIP (For each vaccine, please tick if needed and add any further information in the space provided) Hepatitis A_ Hepatitis B_ Typhoid_ Cholera_ Tetanus Diptheria_ Polio Meningitis ACWY_ Yellow Fever_ Rabies_ Jap B Enceph_ Other (please list _ TRAVEL ADVICE GIVEN AS PER TRAVEL PROTOCOL (Please tick as appropriate) _ Food, water and personal hygiene advice _ Traveller’s diarrhoea _ Hepatitis B and HIV _ Insect bite prevention _ Animal bites _ Accidents _ Insurance _ Air travel _ Sun and heat protection _ Websites _ Travel record card supplied _ Other (please list) MALARIA PREVENTION ADVICE AND MALARIA CHEMOPROPHYLAXIS (Please tick as appropriate) _ Chloroquine and proguanil _ Atovaquone and proguanil (Malarone) _ Chloroquine _ Mefloquine _ Doxycycline Further Information (e.g. weight of child) Signed by: Position: Date: . Appointment Length: Date: Number of Appointments (and intervals): Cost to Patient: 3|Page