Download Traveller Questionnaire - Brailsford Medical Centre

Brailsford & Hulland Medical Practice
TRAVEL HEALTH PLAN QUESTIONNAIRE
This form must be completed and returned to
the surgery at least 6 weeks before you travel
PLEASE READ ALL THE NOTES BELOW BEFORE
COMPLETING
If you require any vaccinations relating to foreign travel you need to
visit the NHS website before completing this form at
www.fitfortravel.nhs.uk. It is important to make this initial visit
to the website as it will guide you through the areas you are visiting
and give you some idea of which vaccinations may be necessary for
your trip. .
The practice nurse will review your travel health questionnaire, and
then contact you to discuss making an appointment at the surgery, if
necessary.
Further appointments may be required with the practice nurse to
receive additional vaccinations. Any subsequent appointments need
to be booked and vaccine courses completed at least 2 weeks
before you travel to allow the vaccines to work.
If you are traveling within four weeks you will need to visit a
travel clinic, details are listed below they offer a similar service to
Brailsford Medical Centre.
MANOR Travel clinic
99-101 St Peters way
Derby
Tel: 01332 347926
Masta Travel Clinic
Nottingham
Tel: 01159 475498
Please note that we are not obliged to provide travel advice but
we choose to do so as a service to our patients. If you do not
allow sufficient time for us to assess your needs and administer
the vaccines we may need to send you to an alternative
provider.
1
Personal Details
Name:
Sex:
Female
Male
Date of Birth:
Daytime Tel:
Email:
Date of Visit
Departure Date:
Duration:
Itinerary and Purpose of Visit
Country
Duration of Stay
Availability of Medical Help *
Trip Description - please tick all appropriate boxes:
Purpose of Trip:
Business
Pleasure
Other
Type of Trip:
Package
Self-Organised
Backpacking
Camping
Cruise Ship
Trekking
Accommodation:
Hotel
Friends/Family
Other
Travelling:
Alone
With Friend/Family
In a Group
Location Type:
Urban
Rural
Altitude over 3000m
Activity Type:
Safari
Adventure
Other
Personal Medical History
List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)
List all allergies that you have (eg. eggs, nuts, antibiotics)
If you have had a serious reaction to a vaccine in the past, which vaccine was it?
List all of your current medications (including oral contraception)
Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?
Yes
Does having an injection cause you to feel faint?
Yes
Do you or any close family members have epilepsy?
Yes
Do you have any history of mental illness including depression or anxiety?
Yes
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Yes
Have you taken out travel insurance?
Yes
If you have a medical condition, have you told your insurance company about it?
Yes
Are you pregnant, planning pregnancy or breast feeding?
Yes
Write below any further information that might be relevant
Vaccination History
Have you ever had any of the following vaccinations / tablets and if so, when?
Tetanus
Yes
Polio
Yes
Diphtheria
Yes
Typhoid
Yes
Hepatitis A
Yes
Hepatitis B
Yes
Meningitis
Yes
Yellow Fever
Yes
Influenza
Yes
Rabies
Yes
Jap B Enceph
Yes
Tick Borne
Yes
Malaria Tablets
Yes
Other
*If you are travelling to an area where medical help will not be to hand please estimate how long it would take to
reach a doctor
Patient’s signature
(Parent’s signature if patient under 16)
Date form returned
Brailsford & Hulland Medical Practice
Travel Medicines Price List
Updated 12th March 2014
Most standard vaccines are available free of charge however more complex vaccines and
their relevant costs are listed below.
Malaria Tablets- Prices shown as a guide for a 14 day holiday.
Amount required will
be tailored to your needs during your consultation with the Practice Nurse.
 Malarone 250mg
 Larium 250mg
 Avloclor 250mg (Chloroquine)
 Paludrine 100mg (Proquanil)
 Doxycycline
£80.70
(23)
£36.24 (8)
£2.18 (14)
£18.62 (98)
£30.65 (44)
The above prices include the cost of a private prescription. If you wish to have
your medicine dispensed elsewhere then there will be a charge of £10 per
prescription.
Vaccines
 Yellow Fever (inc certificate) (single vaccine)
- our patients
- other Practices’ patients

Hepatitis B (course of 3 injections over 6 months)
 Hepatitis B Booster
 Meningitis ACWY (single vaccine)
 Rabies (course of 3 injections over 1 month)
£60
£70
£78
£30
£50
£195 (£65
per dose)
 Japanese Encephalitis (course of 2 injections over 1
month)
Price on
request
(c £195)
 Tick-borne Encephalitis (course of 3 injections over 12
months, the first 2 given within a fortnight offering 90% protection.
Price for 2 injections only - £130)
4
Price on
request
(c £195)