for office use only to be completed by travel nurse

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Pre - Travel Vaccination Questionnaire
Requests for vaccinations require at least 8 weeks’ notice. This is important as some
vaccines do not offer adequate protection until up to 14 days after administration and
others up to 3 months particularly if you intend to travel for more than 1 month and/or to
remote areas. Please note that we cannot guarantee that requests for vaccinations at short
notice will be given by the practice. In these circumstances you may have to contact an
alternative provider.
Vaccinations that may be given for travel supplied by the NHS include Hepatitis A, Typhoid
Tetanus/diptheria/polio.
Below are travel vaccinations that are not provided by the NHS free of Charge. Depending
on your travel risk assessment you may be advised to have these vaccines. Payment can be
made in the form of either cash or cheque and vaccines courses must be paid for in full
before administration.
Rabies
3 Doses
£150 for full course
Rabies booster
1 Dose
£50
Hepatitis B
3 Doses
£105 for full course
Hepatitis B booster
1 Dose
£35
Hepatitis B Junior (Under 16)
3 Doses
£75 for full course
Hepatitis B Junior booster
1 Dose
£25
Japanese Encephalitis
2 Doses
£180 for full course
Any anti-malarial drugs not available for purchase at your pharmacy will be issued on
private prescription only which will incur £5 charge and the cost of the medication is
payable to your pharmacy.
___________________________________________________________________________
It is essential ALL sections are completed to provide accurate travel advice and vaccine
recommendations.
Name:
Date of Birth:
Contact Number:
Date of Departure:
Countries and Specific Areas Travelling to (please give as much info as possible):
Duration of Stay:
Type of Trip (please circle)
Business, Pleasure, Cruise, Adventure, Altitude, Safari,
Trekking, Backpacking, Package.
What type of accomodation (please circle)
Hotel, Holiday resort, Backpacking, Staying with
friends/relatives, Organised tour
Does your journey include travel to rural or remote areas (if YES please specify in more detail, will
you be near a medical centre?)
Have you ever had any travel vaccination at any other surgery or clinic (if YES please specify
which vaccine and date of vaccine)
Have you had a serious reaction to a vaccine before?
Does having an injection make you feel faint?
Do you have any Allergies?
Women Only. Are you pregnant, planning pregnancy or breastfeeding?
Have you undergone Radiotherapy, Chemotherapy or Steroid treatment?
I confirm the information given to be correct to the best of my knowledge and
understanding. I have no reason to think that I might be pregnant. I am aware of all vaccine
charges.
I consent to the vaccines being given as recommended and have had the opportunity to ask
questions. I am aware that all vaccine may have side effects including an allergic reaction /
fever / general fatigue / soreness / redness or swelling at the injection site.
_________________________________
Name
_________________________________
Signed
_______________
Date
FOR OFFICE USE ONLY TO BE COMPLETED BY TRAVEL
NURSE
Travel risk assessment performed? YES / NO
Travel Vaccines recommended for this trip.
Disease Protection
Always
advised
Advised for
travellers at
higher risk
Patient
needs
vaccine
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diptheria
Polio
Meningitis ACWY
Rabies
Yellow Fever
Japanese Encephalitis
Malaria Prevention Needed?
YES/ NO
Which areas needed for?
How many days travelling in these areas?
Chemoprophylaxis Advised.
Malarone
Doxycycline
Chloroquine and Proguanil
Chloroquine
Patient
needs
booster
Patient up
to date
with
vaccine
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