LAINDON HEALTH CENTRE
TRAVEL VACCINATION FORM
NAME:
ADDRESS:
DOB:
DATE:
DOCTOR:
YES
NO
Women: is it possible you are pregnant, or do you plan
to get pregnant within 3 months of travel?
Women: are you breastfeeding?
Are you, a brother, sister or parent epileptic?
Do you have a history of mental illness, anxiety or
depression?
Have you ever had a reaction to a vaccination before?
Are you allergic to any medicines, especially malaria
tablets? If so, which medicines:
Do you take regular medicines?
If so, which medicines:
DATE OF DEPARTURE:
COUNTRIES & RESORTS TO BE VISITED:
TYPE OF TRAVEL:
Urban / hostel / hotel
[ ]
Rural
[ ]
HAVE YOU EVER HAD THESE VACCINES?
VACCINE
DATE
Tetanus:
YES / NO
Polio:
YES / NO
Typhoid:
YES / NO
Other:
TRAVELLING AROUND?
YES / NO
DURATION OF STAY:
Backpacking / ‘living rough’
IN THE LAST 10 YEARS
[ ]
NAME:
ADDRESS:
DOB:
DATE:
DOCTOR:
SECTION BELOW TO BE COMPLETED BY NURSE / DOCTOR
VACCINATION:
DATE OF VACCINATION:
Typhoid
Diphtheria
Tetanus
Polio
MMR
Hepatitis A
Hepatitis B:
1
2
3
[ ]
[ ]
[ ]
£20 charge each injection
Meningitis
Rabies
Jap B Encephalitis
Yellow Fever - available at the Health Centre
£50 charge
(please pay by cash or cheque)
Shenfield Travel Clinic:
01277 200169
Nurse / Doctor signature:
Patient consent:
© Copyright Laindon Health Centre October 2012
NAME:
ADDRESS:
DOB:
DATE:
DOCTOR:
Anti-Malarial Medication
Different parts of the world have different sorts of malaria. Different courses of
medication are needed in different areas and from year to year. We will check
which is the recommended course for you, for this journey, and will mark the
box below.
Treatment recommended:
PC
Proguanil 200mg daily (Paludrine 2 x 100mg tablets) AND Chloroquine
300mg base once a week (= Avloclor 2 x 250mg or Nivaquine 2 x 200mg)
on the same day of the week (buy over the counter).
ME
Mefloquine 1 x 250mg tablet once a week on the same day of the week
(private prescription enclosed). Do not take Mefloquine if you are pregnant,
breastfeeding, epileptic (or parent, sister or brother is epileptic) or have a
history of mental illness. You must not get pregnant within three months of
taking Mefloquine (see over the page). Start the Mefloquine 2 weeks, three
days before departure and for four weeks after your return.
C
Chloroquine 300mg base once a week (=Avloclor 2 x 250mg or Nivaquine
2 x 200mg) on the same day of the week (buy over the counter).
P
Proguanil 200mg daily (Paludrine 2 x 100mg tablets). (Buy over the
counter).
W
No routine medicine needed, but beware of the risk of malaria.
Avoid mosquito bites.
DO
Doxycycline 1 x 100mg tablet daily. NOT FOR CHILDREN UNDER 12
OR PREGNANT WOMEN. Risk of rashes with sun exposure (private
prescription enclosed). Begin 2 days before departure, continue whilst in
malarious area and for 4 weeks after return.
MON Malarone one tablet daily. Begin 2 days before departure, continue whilst in
malarious area and for 7 days after return (private prescription enclosed).
NOT FOR PREGNANT WOMEN. Paediatric tablets for children.
XX
Your trip is unusually long or complicated. Ring ‘Masta’ on: 0906 822 4100
to obtain written instructions on malaria prophylaxis for your journey.
For further information regarding malaria please ring:
Malaria Reference Laboratory: 24 hour helpline - 0906 550 8908
NOTE:
Take the tablets after food. The tablets should be taken from one
week before travel, whilst away and for at least four weeks after
returning home (unless stated otherwise).
MALARIA PRECAUTIONS
Avoiding Mosquito Bites

Reducing the number of bites reduces the chance of infection. Mosquitoes
are most active during the evenings and nights, when clothes should cover
the exposed skin.

Use insect repellents. Apply them to all exposed areas of skin or clothing.

Put mosquito nets around the bed and over the windows. Spray any
mosquitoes that enter the room with a fly spray before going to bed. Close
the windows and doors.

Invest in a ‘bug plug’. These are small devices which fit in international
electricity sockets and generate a vapour which wards off mosquitoes.
Taking Anti-Malarial Drugs

If you go to, or go through, a place where there is malaria you need to take
medicines to stop you from catching it. This is because you are likely to get
bitten by mosquitoes however hard you try to avoid it.
Pregnant Women

Do not travel to an area where there is malaria unless you really have to.
Malaria increases the risks of pregnancy to both mother and baby. You must
not take Doxycycline if you are pregnant or breastfeeding, and you must not
take Mefloquine in the first three months of pregnancy, or get pregnant within
three months of taking it.
NOTE
If you are unsure what to do about your malaria tablets, make an appointment
with the practice nurse.
Your immunisations only provide partial protection against disease. You can still get
ill even if you have had all your vaccinations. While abroad, take great care with
personal hygiene, water and food. For more information consult the latest Traveller’s
Guide to Health (available from the Travel Agent).
If you get “flu-like” symptoms within 3 months of returning home seek your doctor’s
advice.
STAY HEALTHY:
Our records show that you are overdue:
© Copyright Laindon Health Centre October 2012