Download Travel Vaccination questionnaire

Travel Vaccine Questionnaire
Personal detail
Name
Date of birth
Telephone number
Male [
]
female [
]
Date of trip
Date of departure
Return date or overall length of trip
Itinerary and purpose of visit
Countries to be visited
Length of stay
Away from medical help at
destination, if so how remote?
1.
2.
3.
Please tick as appropriate below to best describe your trip
1. Type of trip
2. Holiday type
3.Accomodation
4. Travelling
5. Staying in area which is
6. planned activities
7. Religious Pilgrimage
Business
package
camping
Hotel
alone
Urban
safari
Pleasure
Self-organised
Other
Backpacking
Cruise ship
Relatives/family home
With family /friend
Rural
Trekking
other
In a group
Altitude
Personal history
Have you ever had a serious reaction to a vaccine given
to you before?
Have you recently undergone radiotherapy ,
chemotherapy or steroid treatment
Women only: Are you pregnant or planning pregnancy or
breast feeding?
Have you taken out travel insurance and if you have
medical condition informed the insurance company about
this?
Vaccine History- have you had any of the following vaccines before
Tetanus
Polio
Typhoid
Hepatitis A
Meningitis
Yellow fever
Rabies
Jap B enceph
Other
Diphtheria
Hepatitis B
Influenza
Tick borne
Malaria tablets
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______________________________________
PTO
FOR OFFICIAL USE
Patients name:
Travel risk assessment performed yes [ ]
no [ ]
Travel vaccine recommended for this trip
Disease protection
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow fever
Rabies
Japanese B encephalitis
other
Yes No Patient declined vaccine
Travel advice & leaflets given as per travel protocol
Food, water & personal
Travellers’
hygiene advice
diarrhoea
Insect bite prevention
Animal bites
Insurance
Air travel
Websites
Travel record card supplied
other
Further information
Blood and bodily fluid infection
risks e.g. Hep B
Accidents
Sun & Heat protection
Authorisation for patient specific direction (PSD) use
Assessor’s name: ___________________________________signature_____________ date___________
Prescriber’s name:___________________________________signature_____________date____________
APPT REQUIRED :
details
APPT MADE :
date/time/clinician