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Microsoft word - travel questionnaire.doc

Patient Travel Questionnaire
Please complete this questionnaire and return it as soon as possible.
You may need travel vaccinations depending on the country or countries you intend to visit. Asthe vaccines are not immediately effective, please ask about them as soon as you havebooked, ideally at least 4 weeks before travelling. Please fill in this form and hand it in to thereceptionist. After two working days days you can phone her and make an appointment withthe practice nurse for any injections that are necessary.
9. Are you on any medication or receiving
any ongoing medical treatment? Please
Address.
give details.
Date of Birth.
Remember to take enough supplies to
1. Which countries do you intend to
last until you return home.
visit (including brief stopovers)
.
10. Are you receiving or have you had
radiotherapy within the last 6 months?
2. Will you be staying in hotels or
11. Have you received steroids within
under more primitive conditions such
the last month?
as camping?
12. Have you ever had any of the following
3. Does your journey include:
vaccinations, if so when?
Coastal areas [
Typhoid [ ].
Inland areas [
Tetanus [ ].
Polio [ ].
4. Do you plan any safaris, jungle
Yellow Fever [ ].
exploring or travel in different terrain?
Will you be above 3000m altitude?
Hepatitis A [ ].
13. Have you ever had an adverse reaction
to any immunisation?
5. Departure date.
6. Duration of stay abroad
N.B. It is important to let us know if you
are HIV positive.
7. Are you pregnant or trying to conceive?
Your signature.
8. Are you allergic to anything?
Smallfield Surgery Travel Information Questionnaire Travel Vaccinations
Always refer to green book if in doubt
General contraindications;
Pregnancy or trying to conceive
I confirm that I have discussed thecontraindications to vaccination with Acute illness
History of reaction to preceding doses
HIV - see green book
Contraindications to live vaccine:
Pregnancy
High dose steroids
Immunosuppressive therapy
Malignancy
Impaired immunity
Within 3 months of Gamma-globulin except Yellow fever
HIV
Anaphylactic reaction to eggs (MMR, Influenza and Yellow Fever)
Within 3 months of BCG or 3 weeks of Yellow Fever.
Given by:
Cost/paid
previous
previous
Diptheria
Meningitis
Japanese Encephalitis
Yellow Fever
Any Others
Chemotherapy against Malaria: Tick as appropriate:
Mefloquine (Larium)
Other Chemotherapy
Proguanil
None necessary
Chloroquine
Larium contraindicated if history of severe psychiatric disorder or convulsions or pregnancy.
Paludrine contraindicated in severe renal failure. Nevaquine contraindicated in pregnancy.
Preventative advice
1: Avoiding mosquito bites.
2: Continue chemoprophylaxis for 4 weeks after return.
3: Avoid contaminated food and water.
4: AIDS (Travel packs).
5: Rabies.
6: Sunburn.
7: Altitude sickness if sleeping above 3000 metres.
Smallfield Surgery Travel Information Questionnaire

Source: http://www.smallfieldsurgery.nhs.uk/website/H81638/files/travel_questionnaire.pdf