PORTESHAM SURGERY
PRE-TRAVEL ASSESSMENT QUESTIONNAIRE
* PLEASE COMPLETE AS MUCH INFORMATION AS POSSIBLE (PATIENT/RECEPTIONIST PRIOR TO APPT)
NAME:
DATE OF BIRTH:
DAY TIME CONTACT
TEL NUMBER:
GP:
DEPARTURE DATE **
RETURN DATE **
ALL COUNTRIES/AREAS TO BE VISITED OR TRAVELLING THROUGH
LENGTH OF STAY IN EACH
1.
2.
3.
PURPOSE OF TRIP
Pleasure
Work
Visiting
family/friends
Business/other
HOLIDAY TYPE
Package
Trekking or
backpacking
ACCOMODATION
Hotel
Relatives/private
home
Safari
Lodge/tent
Cruise
Ship/other
TRAVELLING
Alone
With
family/friend
In a group
IF YOU REQUIRE MALARIA TABLETS FOR YOUR TRIP, YOU MAY HAVE TO SEE YOUR GP FOR A
PRESCRIPTION. THE PRACTICE NURSE WILL ADVISE YOU IF YOU ARE NOT SURE.
IF A YELLOW FEVER VACCINATION IS RECOMMENDED FOR YOUR TRIP, THIS VACCINE HAS TO
BE GIVEN AT A REGISTERED YELLOW FEVER CENTRE, SUCH AS WYKE/PUDDLETOWN OR THE
BRIDGES MEDICAL CENTRE AND IS CHARGEABLE.
PLEASE REMEMBER TO ALLOW PLENTY OF TIME TO COMPLETE THE
VACCINATIONS BEFORE YOUR DEPARTURE. MORE THAN ONE VISIT MAY BE
NECESSARY FOR COMPLICATED ITINERARIES.
Drs Baird, Fowler & Beale, Malthouse Meadow, Portesham, Dorset DT3 4NS Tel: 01305 871468
Document1
Updated: February 2015
TRAVEL VACCINATIONS UNDER PATIENT SPECIFIC DIRECTION- PORTESHAM SURGERY
*NURSE TO COMPLETE THIS PAGE
VACCINE
HAD
RECOMMENDED
CONSIDER
DATE
GIVEN AT
PORTESHAM
COST
TETANUS/DIPHTHERIA & POLIO
FREE
TYPHOID
FREE
HEPATITIS A 1
ST
FREE
PAEDIATRIC HEP A
FREE
BOOSTER HEP A
FREE
HEPATITIS B COURSE
CHARGEABLE-APPROX £60-75)
HEPATITIS B BOOSTER
CHARGEABLE- £20-£25
CHOLERA (ORAL)
MAY BE CHARGEABLE
RABIES BOOSTER
CHARGEABLE-£55
RABIES COURSE
CHARGEABLE-£160-£170
MENINGOCOCCAL MENINGITIS
ACWY
MENINGOCOCCAL MENINGITIS
MENVEO
TICK BOURNE ENCEPHALITIS
CHARGEABLE-£30-£35
JAPANESE ENCEPHALITIS
COURSE (Ixiaro) COURSE OF 2
OR 3
JAPANESE
ENCEPHALITIS
BOOSTER
YELLOW FEVER-REFER TO
REGISTERED CENTRE
MALARIA TABLETS
CHARGEABLE-£185-£275
APPROX
CHARGEABLE-£90-£95
CHARGEABLE-£60-£65
CHARGEABLE
NA (USUALLY £50-65)
CHARGEABLE
OTHER
ADVICE DISCUSSED OR LEAFLET GIVEN
LONGHAUL
FLIGHT/DVT/SOCKS
INSURANCE
Y/N
PATIENT SIGNATURE (CONSENT):
BITE
PREVENTION/REPELLANT
PERSONAL SAFETY
Y/N
NURSE SIGNATURE:
DRINK/FOOD HYGIENE
SUN/HEAT STROKE Y/N
GP SIGNATURE:
ALTITUDE
PRE TRAVEL HEALTH/BP
ETC/MEDS
FIRST AID/MEDICATION
ALLERGIES
Y/N
Drs Baird, Fowler & Beale, Malthouse Meadow, Portesham, Dorset DT3 4NS Tel: 01305 871468
Document1
Updated: February 2015