NAME: …………………………………………………DOB:………………………………………
DESTINATION:……………………………………..Departure Date:………………………
Contact number:…………………………………..Surgery:………………………………….
PLEASE ANSWER THE QUESTIONS BELOW AND RETURN THIS FORM TO RECEPTION
1. Have you been advised of the charge for vaccine?
2. Have you been given Information about Yellow Fever?
3. Do you intend to travel within the next 3 weeks?
YES/NO
YES/NO
YES/NO
YES / NO 4. Have you ever had a bad reaction to any previous vaccinations?
5. Are you pregnant or thinking of becoming pregnant? YES / NO
6. Are you allergic to egg products?
7. Have you undergone any drug treatment or have any condition, which affects your immune system?
8. Do you have any condition affecting your thymus gland?
YES / NO
YES / NO
YES / NO
9. Have you suffered from any illness/infections within past 7 days? YES / NO
If you have answered Yes to Q4 - 9 above please give details:……………………………………………….
………………………………………………………………………………………………………………
Signed ................................................................... Date .....................................................
(If under age 16 please ask parent or guardian to sign this form)
PATIENT SPECIFIC DIRECTION: I authorise the patient named above to receive "Stamaril" yellow fever vaccination 0.5ml dose by subcutaneous or intramuscular injection in accordance with
Green Book and Nathnac guidelines by a registered nurse who has attended a Yellow Fever course or update within the past two years.
Signed; ............................................................................... Doctor at South Molton Health Centre
VACCINATION DETAILS; (to be completed by nurse)
Date given:............................................
Nurses initials:………………………………
Batch Number & expiry date:…………………………….
Site given: Left / Right Arm