• TRAVEL VACCINATION CENTRE AT ABBEYDALE PHARMACY Medical Questionnaire

    Please complete before your appointment date
  • Appointment
  • Sex*
  • Format: 00000000000.
  • Purpose of Visit*
  • Do you have a fever today?*
  • Do you have any recent or past medical history of note?*
  • Have you had any immunizations in the past 3 weeks?*
  • Do you have any allergies to eggs, latex, nuts or antibiotics?*
  • Do you take any current or repeat medicines?*
  • Have you had a serious reaction to a vaccine before?*
  • Does having an injection make you feel faint?*
  • Do you or any of your family suffer from epilepsy?*
  • Recently undergone radiotherapy, chemotherapy, steroids?*
  • Do you have a medical history of the following: anxiety, depression,heart, lung, spleen, joint, liver, kidney, immunity, blood conditions,disorders, diabetes, HIV/AIDS*
  • Please write below any further information which may be relevant*
  • Vaccination History. Please select the Vaccines you have had*
  • Are you pregnant? Or planning a pregnancy?*
  • Are you breast feeding?*
  • Personal Medical History. Please select which of the following applies to you.*
  • DO YOU REQUIRE INFORMATION ON MALARIA AND ANTIMALARIALS?*

  • PHARMACIST/ OFFICE USE ONLY

  • ANTIMALARIALS REQUIRED
  • A known hypersensitivity to atovaquone or proguanil hydrochloride or any component of the formulation question?*
  • Known severe renal impairment (creatinine clearance < 30mL/min)*
  • Patients taking the following drugs:*
  • Lack of experience in pregnancy and during breast feeding means that it should be avoided in these circumstances unless there is no suitable alternative*
  • Post-exposure treatment*
  • Valid patient consent*
  • Patient weighs less than 5 kg;*
  • 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.*
  • Are you breastfeeding? If yes women should be referred to their GP for advice*
  • DOXYCYCLINE INCLUSION
  • DOXYCYCLINE EXCLUSION
  • PHARMACIST USE ONLY: VACCINE REQUIREMENTS
  • 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 ?*
  • TravelHealthPro recommendations link
  • Should be Empty: