TRAVEL VACCINATION CENTRE AT ABBEYDALE PHARMACY Medical Questionnaire
Please complete before your appointment date
Appointment
Full Name
*
First Name
Last Name
Date of Birth
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Sex
*
Male
Female
E-mail Address
*
example@example.com
Contact Number
*
Format: 00000000000.
Home Address
*
Street Address
Street Address Line 2
City
County
Post Code
GP Practice Details
*
Please include practice name and address.
Trip Dates
Departure date
Return date
Itinerary- Please enter the countries you will be visiting.
*
Country
Length of Stay
Country 2
Country
Length of Stay
Country 3
Country
Length of Stay
Country 4
Country
Length of Stay
Purpose of Visit
*
Remote Area Visit
Visiting friends and family
Healthcare Worker
Pilgrimage
Medical Tourism
Charity Worker
Long-term (Expatriate/ Volunteer/ Backpacker)
Tourism
Other
Do you have a fever today?
*
Yes
No
Please provide details.
Do you have any recent or past medical history of note?
*
Yes
No
Please provide details.
Have you had any immunizations in the past 3 weeks?
*
Yes
No
Please provide details.
Do you have any allergies to eggs, latex, nuts or antibiotics?
*
Yes
No
Please provide details.
Do you take any current or repeat medicines?
*
Yes
No
Please provide details.
Have you had a serious reaction to a vaccine before?
*
Yes
No
Please provide details.
Does having an injection make you feel faint?
*
Yes
No
Please provide details.
Do you or any of your family suffer from epilepsy?
*
Yes
No
Please provide details.
Recently undergone radiotherapy, chemotherapy, steroids?
*
Yes
No
Please provide details.
Do you have a medical history of the following: anxiety, depression,heart, lung, spleen, joint, liver, kidney, immunity, blood conditions,disorders, diabetes, HIV/AIDS
*
Yes
No
Please provide details.
Please write below any further information which may be relevant
*
Yes
No
Please provide details.
Vaccination History. Please select the Vaccines you have had
*
Diptheria
Influenza
Meningitis B or ACWY
Tetanus
Yellow Fever
Hepatitis A
Hepatitis B
Polio
Tick Borne
Rabies
Typhoid
Japanese B Encephalitis
None
Other
Please provide dates of when you had the vaccines
Are you pregnant? Or planning a pregnancy?
*
Yes
No
Are you breast feeding?
*
Yes
No
Personal Medical History. Please select which of the following applies to you.
*
Allergies (including food, latex, medication etc.)
Anaemia
Bleeding/ clotting disorders (including deep vein thrombosis)
Diabetes
Disability
Gastrointestinal (stomach) complaints
Heart disease (e.g. angina, high blood pressure)
HIV/AIDS
Immune system condition
Kidney problems
Liver problems
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
None
Other
DO YOU REQUIRE INFORMATION ON MALARIA AND ANTIMALARIALS?
*
YES
NO
DON'T KNOW
PHARMACIST/ OFFICE USE ONLY
ANTIMALARIALS REQUIRED
MALARONE (ATOVAQUONE/ PROGUANIL)
MALARONE PAED (ATOVAQUONE/ PROGUANIL)
DOXYCYCLINE
LARIAM (MEFLOQUINE)
A known hypersensitivity to atovaquone or proguanil hydrochloride or any component of the formulation question?
*
YES
NO
Known severe renal impairment (creatinine clearance < 30mL/min)
*
YES
NO
Patients taking the following drugs:
*
Rifampicin
Rifabutin
Metoclopramide
Efavirenz boosted protease-inhibitors
Tetracycline
Etoposide
Concomitant use of tetracyclines, metoclopramide
Warfarin other coumarin-based anticoagulants
NONE OF THE ABOVE
Lack of experience in pregnancy and during breast feeding means that it should be avoided in these circumstances unless there is no suitable alternative
*
AVOID
NOT AVOID
NA
Post-exposure treatment
*
YES
NO
Valid patient consent
*
YES
NO
Patient weighs less than 5 kg;
*
YES
NO
Pregnant women should be referred to their GP for advice. Travel to malarious areas should be avoided during pregnancy; if travel is unavoidable, effective prophylaxis must be used. Chloroquine and proguanil can be given in the usual doses during pregnancy, but these drugs are not appropriate for most areas because their effectiveness has declined, particularly in SubSaharan Africa. I understand the above statement and have received instruction from my GP to continue with treatment.
*
YES
NO
Are you breastfeeding? If yes women should be referred to their GP for advice
*
YES
NO
DOXYCYCLINE INCLUSION
DOXYCYCLINE EXCLUSION
PHARMACIST USE ONLY: VACCINE REQUIREMENTS
CHOLERA
DTP
HEP A
HEP B
JAPANESE ENCEPHALITIS
MENINGITIS ACWY
MENINGITIS B
MMR
RABIES
TYPHOID
TICK BORNE
If under 16 are paediatric doses indicated
Hep A- Havrix Junior
Vaccine Administration
CHOLERA INCLUSION-
MENINGITIS ACWY INCLUSION- People of all ages at risk of exposure to Neisseria meningitidis groups A, C, W135 and Y, including:
MMR INCLUSION-
TICK BORNE INCLUSION-
TICK BORNE EXCLUSION-
DTP INCLUSION
HEP A INCLUSION
JAPANESE ENCEPHALITIS INCLUSION
HEP B INCLUSION- Hepatitis B vaccine is recommended for travellers over 16 years of age, visiting areas of hepatitis B risk, who put themselves at risk of infection
RABIES INCLUSION- Patients any age, visiting areas of rabies risk. Most international travellers to rabies enzootic areas are considered to be at infrequent risk, but may require pre-exposure rabies vaccine if they are:
TYPHOID INCLUSION-
PLEASE CONFIRM THE FOLLOWING FOR HEP A
*
PLEASE CONFIRM THE FOLLOWING FOR TYPHOID
*
PLEASE CONFIRM THE FOLLOWING FOR JAPANESE ENCEPHALITIS
*
PLEASE CONFIRM THE FOLLOWING FOR DTP
*
PLEASE CONFIRM THE FOLLOWING FOR MMR
*
PLEASE CONFIRM THE FOLLOWING FOR HEP B
*
PLEASE CONFIRM THE FOLLOWING FOR MENINGITIS ACWY
*
PLEASE CONFIRM THE FOLLOWING FOR RABIES
*
PLEASE CONFIRM THE FOLLOWING FOR CHOLERA
*
Is a check for BP necessary ?
*
YES
NO
PATIENT CONSENT: I HAVE HAD A CONVERSATION WITH THE PHARMACIST AND CONSENT TO RECEIVE THE VACCINES LISTED ON THIS FORM. I HAV EALSO HAD THE OPPORTUNITY TO ASK ANY QUESTIONS REGARDING THE CONSULTATION. SIGNED:
Submit Form
Should be Empty: