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Download Travel Questionnaire - Riverside Medical Practice
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Riverside Medical Practice Travel Questionnaire PLEASE COMPLETE AND HAND IN TO THE PRACTICE (ONE FORM PER PERSON) 4 WEEKS BEFORE DATE OF TRAVEL IF POSSIBLE. PLEASE ENSURE YOU ENTER VALID CONTACT TELEPHONE NUMBERS FOR THE NURSE TO CALL YOU TO ARRANGE YOUR VACCINES. Personal Details Name: Date of Birth: Daytime Tel: Sex: Female Postcode: Mobile Tel: Trip Dates Departure Date: Total Duration: Itinerary – in order first to last Countries Duration Male Availability of Medical Help Trip Description – please tick all appropriate boxes Purpose of Trip: Business Pleasure Type of Trip: Package Immigration Cruise Elective/student Accommodation: Good Basic Travelling: Alone With Friend/Family Location Type: Urban Rural Beach Other Voluntary/charity work Organised adventure trip Poor/not known In a Group Altitude >3000m Personal Medical History List all chronic medical conditions that you have (e.g. diabetes, heart or lung conditions): List all allergies that you have (e.g. 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 No Does having an injection cause you to feel faint? Yes No Do you or any close family members have epilepsy? 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 Have you taken out travel insurance? Yes No If you have a medical condition, have you told your insurance company about it? Yes No Are you: Pregnant Planning Pregnancy Breastfeeding 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 Polio Diptheria Typhoid Hepatitis A Hepatitis B Meningitis Yellow Fever Influenza Rabies Jap B Enceph Tick Borne Malaria tablets Other OFFICE USE ONLY: Risks Discussed Bite Avoidance Schistosomiasis Other – please specify: Vaccines: Vaccines Food/Water Hygiene Insurance/Accidents Received previously / Comments Signature: Rabies Dates Poliomyelitis Tetanus Diptheria / Tetanus / Inactivated Polio Typhoid (injectable) Hepatitis A Hepatitis B Hepatitis A & Typhoid combined Hepatitis A & B Combined Meningococcal (specify type) Japanese B Encephalitis Rabies Tick-borne encephalitis Yellow Fever Cholera Mantoux B.C.G. Other Chloroquine Blood Borne Viruses Sun Protection Result: Result: Proguanil Doxycycline Malaria Prophylaxis advised Mefloquine Atovaquone/Progunil Date: None
