Microsoft word - travel vaccination questionnaire pdf.doc
TRAVEL VACCINATION QUESTIONNAIRE Page 1 of 3
Please complete this form prior to your travel appointment and return to reception Personal details
Date of birth: Male [ ] Female [ ] Easiest contact telephone number E mail Dates of trip Date of Departure Return date or overall length of trip Itinerary and purpose of visit Country to be visited Length of stay Away from medical help at destination, if so, how remote? Please tick as appropriate below to best describe your trip 1. Type of trip 2. Holiday type 3. Accommodation 4. Travelling 5. Staying in area which is 6. Planned activities
Marske: Windy Hill Lane, TS11 7BL. Tel : 01642 477133
Saltburn: 2 Windsor Rd, TS12 1BH. Tel : 01287 622393
TRAVEL VACCINATION QUESTIONNAIRE Page 2 of 3 Personal medical history Do you have any recent or past medical history of note? (Including diabetes, heart or lung conditions or Spleen Removal) Are you taking any medication? 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? Do you or any close family members have epilepsy? Do you have any history of mental illness, including depression or anxiety? 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 a medical condition, informed the insurance company about his? Please write below any further information which may be relevant Vaccination History Including Childhood and School Vaccines Have you ever had any of the following vaccinations / malaria tablets and if so when? Tetanus
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 ________
Marske: Windy Hill Lane, TS11 7BL. Tel : 01642 477133
Saltburn: 2 Windsor Rd, TS12 1BH. Tel : 01287 622393
TRAVEL VACCINATION QUESTIONNAIRE Page 3 of 3 For official use Patient Name:
Travel risk assessment performed Yes [ ] No [ ] TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
Disease protection Further information TRAVEL ADVICE AND LEAFLETS GIVEN AS PER TRAVEL PROTOCOL
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
FUTHER INFORMATION e.g. weight of child Signed by: Position: Date: I give consent to the administration of the vaccines recommended above Patient Name: Signature
PLEASE NOTE IT IS THE PATIENTS RESPONSIBILITY TO CONTACT THE SURGERY AFTER 5 WORKING DAYS FOR DETAILS OF ANY IMMUNISATIONS OR MEDICATIONS REQUIRED.: Tel: 01642 477133 or 01287 622393
Marske: Windy Hill Lane, TS11 7BL. Tel : 01642 477133
Saltburn: 2 Windsor Rd, TS12 1BH. Tel : 01287 622393
HIGHLIGHTS OF PRESCRIBING INFORMATION WARNINGS AND PRECAUTIONS These highlights do not include all the information needed to use Carisoprodol safely • Due to sedative properties, may impair ability to perform hazardous tasks such as driv- and effectively. See full prescribing information for Carisoprodol. ing or operating machinery (5.1)• Additive sedative effects when used with o
The Management of Premature Ejaculation: A Patient’s Guide How does ejaculation occur? Ejaculation, control ed by the central nervous system, happens when friction on the genitalia and other forms of sexual stimulation provide impulses that are sent up the spinal cord and into the brain. Ejaculation has two phases: PHase i: emission The vas deferens (the tubes that store and transport
