Download Personal Details - The Suttons Medical Group

Suttons Medical Group Travel Questionnaire
Travel health consultations are provided free to our patients on the
NHS as an additional service.
However if you book an appointment and then DO NOT ATTEND
YOU WILL BE INVOICED A CHARGE FOR THE
APPOINTMENT TIME WASTED.
Please cancel any appointments that you can not attend giving plenty
of notice and reschedule at a convenient time.
Adapted from Travel Risk Assessment Form, © Travel Health Training Ltd. 2005
Page 1 of 5 03/06/11 Michele Bradley updated 07/08/14 WL
Suttons Medical Group Travel Questionnaire
Appointment Booked:
Office use:
Appt Time Needed:
Date:
Personal Details
Name:
Date Of Birth:
Male [ ]
Female [ ]
Easiest contact telephone number:
Address:
Travel Details
Departure Date:
Email:
Reason For
travel
Tick
Boxes
Holiday 1-28 days
Holiday 28 days or
more
Return Date:
Method of
Tick
travel
Box
Long haul flight
Short haul flight
Ferry/Boat
Train
Car
Cruise:
Cruise company
Cruise Number
Please attach itinerary
Other (describe)
Other Destinations
Country
Time:
Business Trip
Visiting friends or
relatives
Gap Year
Voluntary work
What type?
Other (Describe)
Do you travel abroad?
Once a year
Twice a Year
More Frequently
Hardly Ever
Region
Final destination
Country
Resort or
port
Region
Urban or
Rural
High
Altitude
Going anywhere else during
your journey?
E.G. to change flights, join
cruise, island hop, visit tourist
attractions, game parks,
waterfalls etc
YES/NO
If Yes please
give details below
Resort/port
Length of Stay
Please attach destinations on separate sheet if too many to list here
Please tick as appropriate to best describe your trip
Accommodation
Planned Activities
Travelling
Hotel
Self catering
apartment/villa
Safari
Alone
Walking in woodland
With family/friends
Private Home
Climbing/Trekking at
high altitude
Snorkelling
Camping
Scuba/Sub aqua diving
Sleeping Rough/
Adventure
Hostel
In a group
Other information
More than 24 hours
from medical care?
Mixing closely with
Adapted from Travel Risk Assessment Form, © Travel Health Training Ltd. 2005
Page 2 of 5 03/06/11 Michele Bradley updated 07/08/14 WL
Suttons Medical Group Travel Questionnaire
Backpacking
local population?
Personal Medical History
Do you have any recent or past medical history of note? (Including diabetes, heart or lung
conditions, thymus disorder)
List any current or repeat medications
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Have you ever had a Pulmonary Embolus (PE) or Deep Vein Thrombosis (DVT)?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the
insurance company about this?
Women only: Are you pregnant or planning pregnancy or breast feeding?
Please write below 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
Jap B
Tick Borne
Encephalitis
Encephalitis
Rabies
Other
Malaria tablets
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.
Signed __________________________________________ Date ________
Adapted from Travel Risk Assessment Form, © Travel Health Training Ltd. 2005
Page 3 of 5 03/06/11 Michele Bradley updated 07/08/14 WL
Suttons Medical Group Travel Questionnaire
NB. All travel consultations are carried out at SUTTON BRIDGE
SURGERY
For official use
Patient Name:
Sign
Date
Form received
Travax Printed
Processed by
nurse
Travel risk assessment performed Yes [ ]
No [ ]
TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
Vaccines advised
Yes
Date
had
Further information
Diphtheria
Hepatitis A
Polio
Tetanus
Typhoid
Yellow Fever
Vaccines to consider
Cholera
Hepatitis B
Japanese B Encephalitis
Measles (MMR)
Meningitis ACWY
Rabies
Tick Borne Encephalitis
Other
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
Is there a risk of malaria?
Y/N
Length of trip _________ NIGHTS
Aware/understanding e.g. how
contracted?
Bite avoidance discussed?
Y/N
Drug
Y/N
Chloroquine
Signs/symptoms/diagnosis
Y/N
Proguanil
Malaria advice leaflet given
Y/N
Doxycycline
FURTHER INFORMATION
No. tablets
Prescriber’s
Signature
Malarone
e.g. weight of child
Mefloquine
Planned vaccine schedule for current trip
Vaccine
Day 0
Day
Day
Day
Adapted from Travel Risk Assessment Form, © Travel Health Training Ltd. 2005
Page 4 of 5 03/06/11 Michele Bradley updated 07/08/14 WL
Prescriber’s
Signature
Suttons Medical Group Travel Questionnaire
Signed by:
Position:
Date:
Adapted from Travel Risk Assessment Form, © Travel Health Training Ltd. 2005
Page 5 of 5 03/06/11 Michele Bradley updated 07/08/14 WL