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
NAME ________________________ DATE OF BIRTH _________________
________________________________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.
Rabies ₤17.00 Prescription charge + Pharmacy fee
*Meningococcal Payment of ₤ 45.00 before order.
*Japanese B Encephalitis Payment of ₤120.00 before order.
* 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
Advice to the Diabetic Patient who wants to FAST during the Holy month of Ramadan: By: Dr M Akber, Consultant Physician in Diabetes & Endocrinology University Hospital of North Staffordshire, Stoke on Trent, UK Contact: email@example.com This article includes: 1. General issues and advice to the patient during Ramadan fasting (sawm) 2. Specific advice to the physician, and
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