TRAVEL VACCINATION CENTRE Medical Questionnaire

TRAVEL VACCINES Medical Questionnaire DARNALL PHARMACY

Please complete before your appointment date
Appointment
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Sex*

MaleFemale
E-mail Address*
example@example.com
Contact Number*
Home Address*

Street Address

Street Address Line 2

CityCounty

Post Code
GP Practice Details*
Please include practice name and address.
Trip Dates

Departure dateReturn date
Itinerary- Please enter the countries you will be visiting.*

CountryLength of Stay
Country 2

CountryLength of Stay
Country 3

CountryLength of Stay
Country 4

CountryLength of Stay
Purpose of Visit*

Remote Area VisitVisiting friends and familyHealthcare WorkerPilgrimageMedical TourismCharity WorkerLong-term (Expatriate/ Volunteer/ Backpacker)TourismOther
Do you have a fever today?*

YesNo
Please provide details.
Do you have any recent or past medical history of note?*

YesNo
Please provide details.
Have you had any immunizations in the past 3 weeks?*

YesNo
Please provide details.
Do you have any allergies to eggs, latex, nuts or antibiotics?*

YesNo
Please provide details.
Do you take any current or repeat medicines?*

YesNo
Please provide details.
Have you had a serious reaction to a vaccine before?*

YesNo
Please provide details.
Does having an injection make you feel faint?*

YesNo
Please provide details.
Do you or any of your family suffer from epilepsy?*

YesNo
Please provide details.
Recently undergone radiotherapy, chemotherapy, steroids?*

YesNo
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*

YesNo
Please provide details.
Please write below any further information which may be relevant*

YesNo
Please provide details.
Vaccination History. Please select the Vaccines you have had*

DiptheriaInfluenzaMeningitis B or ACWYTetanusYellow FeverHepatitis AHepatitis BPolioTick BorneRabiesTyphoidJapanese B EncephalitisNoneOther
Please provide dates of when you had the vaccines
Are you pregnant? Or planning a pregnancy?*

YesNo
Are you breast feeding?*

YesNo
Personal Medical History. Please select which of the following applies to you.*

Allergies (including food, latex, medication etc.)AnaemiaBleeding/ clotting disorders (including deep vein thrombosis)DiabetesDisabilityGastrointestinal (stomach) complaintsHeart disease (e.g. angina, high blood pressure)HIV/AIDSImmune system conditionKidney problemsLiver problemsMental health issues (including anxiety, depression)Neurological (nervous system) illnessRespiratory (lung) diseaseRheumatology (joint) conditionsSpleen problemsNoneOther
DO YOU REQUIRE INFORMATION ON MALARIA AND ANTIMALARIALS?*

YESNODON'T KNOW
PHARMACIST/ OFFICE USE ONLY
ANTIMALARIALS REQUIRED

MALARONE (ATOVAQUONE/ PROGUANIL)MALARONE PAED (ATOVAQUONE/ PROGUANIL)DOXYCYCLINELARIAM (MEFLOQUINE)
A known hypersensitivity to atovaquone or proguanil hydrochloride or any component of the formulation question?*

YESNO
Known severe renal impairment (creatinine clearance < 30mL/min)*

YESNO
Patients taking the following drugs:*

RifampicinRifabutinMetoclopramideEfavirenz boosted protease-inhibitorsTetracyclineEtoposideConcomitant use of tetracyclines, metoclopramideWarfarin other coumarin-based anticoagulantsNONE 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*

AVOIDNOT AVOIDNA
Post-exposure treatment*

YESNO
Valid patient consent*

YESNO
Patient weighs less than 5 kg;*

YESNO
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.*

YESNO
Are you breastfeeding? If yes women should be referred to their GP for advice*

YESNO
DOXYCYCLINE INCLUSION
DOXYCYCLINE EXCLUSION
PHARMACIST USE ONLY: VACCINE REQUIREMENTS

CHOLERADTPHEP AHEP BJAPANESE ENCEPHALITISMENINGITIS ACWYMENINGITIS BMMRRABIESTYPHOIDTICK 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 ?*

YESNO
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:
Should be Empty:

TRAVEL VACCINES Medical Questionnaire DARNALL PHARMACY