ASHLEIGH SURGERY TRAVEL CLINIC
Immunizations should be commenced at least 8 weeks before travel to give maximum protection .
Please fill in the questionnaire and return it to reception. Make an appointment to see the nurse. If your departure date is within six weeks please make an appointment as soon as possible.
Risks of different diseases vary in different parts of a country so please be as specific as possible when you complete the form.
NAME .
ADDRESS
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TEL. NO DATE OF BIRTH ..
DATE OF TRAVEL ..
Please list all the countries in the order of visiting and indicate the type of holiday you have planned.
Type: (a) Staying in hotels (b) on safari (c) back packing. Add details of any high risk activity eg health care work.
COUNTRY |
AREA eg. City, Jungle, North or South
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LENGTH OF STAY - Days or Weeks
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TYPE As above (a, b or c) |
1 |
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2.
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3.
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4.
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Have you been immunised previously? Please give details if known
INJECTION |
DATE OF LAST INJECTION
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TYPE GIVEN i.e. 1st,2nd, Booster
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IMMUNIZATION REQUIRED (PRACTICE NURSE ONLY)
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Tetanus |
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Polio |
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Typhoid |
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Hepatitis A |
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Hepatitis B |
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Meningitis |
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Diphtheria |
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Others |
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YES |
NO |
Are you allergic to any medicines? |
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Have you reacted badly to any previous vaccine or anti- malarial drug? |
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Are you taking steroids? e.g. Prednisolone |
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Are you pregnant or planning to become pregnant? |
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Have you ever suffered from Epilepsy or convulsions? |
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Have you ever suffered from a psychiatric illness? |
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A private prescription will be issued for anti- malarial drugs. The cost of the drugs varies considerably. The nurse will discuss the options with you.
I can confirm the above answers to be correct to the best of my knowledge and wish my travel details to be processed.
I understand that some injections are not available under the NHS. I agree to pay those charges which will be discussed with me prior to the commencement of immunisation.
Signed Date .
FOR PRACTICE USE ONLY BELOW THIS POINT
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Recommended immunisations as per Travax |
Is patient already covered |
Fee payable if outside NHS |
Fee paid |
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ANTIMALARIALS |
Recommended or alternative regime |
Dose (Adult) |
Duration of prophylaxis |
Total needed |
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Proguanil |
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200mg OD |
1 wk before,4 weeks after |
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Chloroquine |
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2 tabs weekly |
1 wk before 4 weeks after |
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Mefloquine |
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250mg weekly |
1 wk before,4 weeks after |
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Malarone |
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1 Tab OD |
2 days before,7 days after |
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Doxycycline |
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100mg OD |
3 days before,4 weeks after |
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Doctor's Signature Date .