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Confidential travel vaccination questionnaire

CONFIDENTIAL TRAVEL VACCINATION QUESTIONNAIRE
For travel ing abroad you may require vaccinations and health advice. Please complete this questionnaire and hand it in at reception.
Please telephone after 48 hours to ascertain if a travel consultation is necessary. It is advisable to complete this form 6 –
8 weeks prior to travel ing as multiple appointments may be required.
Please complete this form with a black pen
DATE___________

NAME ________________________ DATE OF BIRTH _________________


ADDRESS ______________________________________________________


________________________________TEL NO ________________________


Departure Date ____________ Duration of stay abroad _________________


Type of accommodation __________________________________________________
Please list, in sequence, which countries and regions you plan to visit, including any safaris, jungle expeditions and overland trekking
you plan to do. Are you al ergic to anything? _________________________________________________ Are you pregnant / planning a pregnancy or breastfeeding?_________________________ Do you suffer with any long term medical conditions?______________________________ Are you taking any regular medication (for long term conditions)_____________________ Have you had any of the fol owing vaccinations, including boosters. If so, please indicate the date/s. Hepatitis A YES / NO ____________ Japanese B Encephelitis YES / NO ___________ Typhoid YES / NO ____________ Hepatitis B YES / NO ____________ Tetanus YES / NO ___________ Yel ow Fever YES / NO ____________ Polio
Rabies YES / NO ____________ Meningococcal YES / NO ___________

TO BE COMPLETED BY NURSE


The recommended vaccinations for your travel are circled. If the letter M is present, this means it is mandatory and wil require a
certificate of proof of vaccination. Certificate/booklet charge is ₤10.00.
_________________________________________________________________________________________ Hepatitis A
Rabies ₤17.00 Prescription charge + Pharmacy fee
*Meningococcal Payment of ₤ 45.00 before order.

Hepatitis B

₤30.00
*Japanese B Encephalitis Payment of ₤120.00 before order.

Yellow Fever

₤55.00
Tetanus/Diphtheria/Polio YES/NO
* PAYMENT REQUIRED BEFORE ORDER IS PLACED NO REFUND WILL BE GIVEN ON ORDERED VACCINES

Malaria Tablets recommended ₤3.50 PER TABLET.

Lariam or Doxycycline are issued on a private prescription a charge of ₤17.00 applies + pharmacy fees
Comments:

Please bring the correct money with you or pay by credit card admin fees applies. We NO

longer accept cheque payments. We DO NOT keep money on the premises and may not be able
to give you change. Reception / Nurse will inform you of the charges. Thank you

Source: http://www.kingstonhealthcentre.nhs.uk/website/H84061/files/TRAVELQUESTIONNAIRE2011.pdf

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