ࡱ>  dbjbj bee/+PP8,2!!!!#R%< '1111111$P471']#"#''1!!`2/+/+/+'F!!1/+'1/+/+:Y0,0! VO~'R0 u1v2020R7E(Z7070''/+'''''11)'''2''''7'''''''''P p: Travel Health Questionnaire Please start this process at least six weeks prior to travel. If possible, the immunisation course should be completed three weeks before travel to ensure immunity has developed. Please complete the Questionnaire (print or complete on-line). One questionnaire is required for each member of the family travelling. Once completed, see below for details of where to send the questionnaire. Personal Details Name:  FORMTEXT       Date of Birth:  FORMTEXT       Age:  FORMTEXT       Gender:  FORMDROPDOWN  Contact telephone number:  FORMTEXT       Email:  FORMTEXT       Dates of trip: Date of Departure:  FORMTEXT       Return date:  FORMTEXT        Itinerary & Purpose of Visit Country to be visitedLength of stayHow close to medical help? - At destination / Remote?1.  FORMTEXT       FORMTEXT       FORMDROPDOWN   FORMTEXT      2.  FORMTEXT       FORMTEXT       FORMDROPDOWN   FORMTEXT      3.  FORMTEXT       FORMTEXT       FORMDROPDOWN   FORMTEXT      Future travel plans:  FORMTEXT       Please tick as appropriate below to best describe your trip Type of trip FORMCHECKBOX  Business FORMCHECKBOX  Pleasure  FORMCHECKBOX  Other Holiday type FORMCHECKBOX  Package  FORMCHECKBOX  Self organised  FORMCHECKBOX  Backpacking  FORMCHECKBOX  Camping  FORMCHECKBOX  Cruise ship  FORMCHECKBOX  Trekking Accommodation FORMCHECKBOX  Hotel  FORMCHECKBOX  Family home FORMCHECKBOX  Other Travelling FORMCHECKBOX  Alone FORMCHECKBOX  with family/friend FORMCHECKBOX  In a group Staying in area which is FORMCHECKBOX  Urban  FORMCHECKBOX  Rural  FORMCHECKBOX  Altitude  FORMCHECKBOX  Coastal  FORMCHECKBOX  Inland  FORMCHECKBOX  Jungle Planned activities FORMCHECKBOX  Safari  FORMCHECKBOX  Adventure  FORMCHECKBOX  Other Will you be living or mixing closely with local people?   FORMCHECKBOX  Yes  FORMCHECKBOX  No Personal Medical History Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)  FORMTEXT       List any current or repeat medications:  FORMTEXT       Do you have any allergies e.g. to eggs, antibiotics, nuts?  FORMTEXT       Have you ever had a serious reaction to a vaccine given to you before?  FORMTEXT       Does having an injection make you feel faint?  FORMTEXT       Do you or any close family members have epilepsy?  FORMTEXT       Do you have any history of mental illness including depression or anxiety?  FORMTEXT       Have you recently undergone radiotherapy, chemotherapy or steroid treatment?  FORMTEXT       Women only: Are you pregnant or planning pregnancy or breast feeding?  FORMTEXT      Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?  FORMTEXT       Please write below any further information which may be relevant:  FORMTEXT        Vaccination history Have you ever had any of the following vaccinations / malaria tablets and if so when?  FORMCHECKBOX  Tetanus  FORMTEXT        FORMCHECKBOX  Polio  FORMTEXT       FORMCHECKBOX  Diphtheria  FORMTEXT       FORMCHECKBOX  Typhoid  FORMTEXT       FORMCHECKBOX  Hepatitis A  FORMTEXT       FORMCHECKBOX  Hepatitis B  FORMTEXT       FORMCHECKBOX  Meningitis  FORMTEXT       FORMCHECKBOX  Yellow Fever  FORMTEXT       FORMCHECKBOX  Influenza  FORMTEXT       FORMCHECKBOX  Rabies  FORMTEXT       FORMCHECKBOX  Jap B Enceph  FORMTEXT       FORMCHECKBOX  Tick Borne  FORMTEXT       FORMCHECKBOX  Other which ones?  FORMTEXT        FORMCHECKBOX  Malaria tablets which ones?  FORMTEXT       Thank you for taking time to complete the questionnaire. Please email the completed questionnaire to  HYPERLINK "mailto:contact@homevisitdoctor.co.uk" contact@homevisitdoctor.co.uk. Once submitted, you will be contacted by our administration team and a fee of 35 will charged prior to the doctor recommending which vaccinations are appropriate for you. This fee is fully refundable if you choose to have your vaccinations with Home Visit Doctor. Once the doctor has reviewed your circumstances, the doctor will contact you to confirm which vaccinations are recommended and arrange an appointment for administration. The remaining balance for the cost of the vaccines will be required to be charged in advance, so the vaccines can be ordered. USEFUL WEBSITES:  HYPERLINK "http://www.nathnac.org" www.nathnac.org  HYPERLINK "http://www.fitfortravel.nhs.uk" www.fitfortravel.nhs.uk  HYPERLINK "http://www.travelhealth.co.uk" www.travelhealth.co.uk  HYPERLINK "http://www.fco.gov.uk" www.fco.gov.uk FOR OFFICIAL USE Patient Name:  FORMTEXT %;AEh0 M Z пппппбtccQChCJOJQJ^JaJ#jhCJOJQJU^JaJ hohCJOJQJ^JaJ#hoh5CJOJQJ^JaJh5CJOJQJ^JaJhNu CJOJQJ^JaJhRyCJOJQJ^JaJhoCJOJQJ^JaJ hoh;CJOJQJ^JaJh;CJOJQJ^JaJ&hoh5V5>*CJOJQJ^JaJjh;UmHnHu  p uuu.d$$d%d&d'dIfNOPQgd&$d%d&d'dNOPQgd^gd; $r^ra$gdNu $r^ra$gd $^a$gd;$a$gd5V   4 6 J L N X Z \ j l دءدءwءeWB)jrhnTCJOJQJU^JaJhnTCJOJQJ^JaJ#jhnTCJOJQJU^JaJ)jhCJOJQJU^JaJ)jthCJOJQJU^JaJhCJOJQJ^JaJ hohCJOJQJ^JaJ.jhCJOJQJU^JaJmHnHu#jhCJOJQJU^JaJ)jhCJOJQJU^JaJ      ( * 2 6 D H J ^ ` b l n p μߧ߼zhYhμh>*CJOJQJ^JaJ#hoh>*CJOJQJ^JaJ)jhCJOJQJU^JaJ.jhCJOJQJU^JaJmHnHu)jhCJOJQJU^JaJ#jhCJOJQJU^JaJ hohCJOJQJ^JaJhCJOJQJ^JaJ#jhnTCJOJQJU^JaJp r " $ ?$Ifgd.dh$$d%d&d'dIfNOPQgd+$$d%d&d'dIfNOPQgd     " $ & < X b دءء{iWHW7 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 FORMDROPDOWN  Doctor performing assessment:  FORMTEXT       Travel vaccines recommended for this trip Disease protectionYesNoFurther informationHepatitis A FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Hepatitis B FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Typhoid FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Cholera FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Tetanus FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Diphtheria FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Polio FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Meningitis ACWY FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yellow Fever FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Japanese B Encephalitis FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Rabies FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Other FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       Travel advice and leaflets given as per travel protocol Food water and personal hygiene advice FORMCHECKBOX Travellers diarrhoea FORMCHECKBOX Hepatitis B and HIV FORMCHECKBOX Insect bite prevention FORMCHECKBOX Animal bites FORMCHECKBOX Accidents FORMCHECKBOX Insurance FORMCHECKBOX Air travel FORMCHECKBOX Sun and heat protection FORMCHECKBOX Websites FORMCHECKBOX Travel Record card supplied FORMCHECKBOX Other  FORMCHECKBOX   FORMTEXT       Malaria prevention advice and malaria chemoprophylaxis Chloroquine and proguanil FORMCHECKBOX Atovaquone + proguanil (Malarone) FORMCHECKBOX Chloroquine FORMCHECKBOX Mefloquine FORMCHECKBOX Doxycycline FORMCHECKBOX Malaria advice leaflet given FORMCHECKBOX  Further information e.g. weight of child  FORMTEXT       For discussion when risk assessment is performed within your appointment: I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given. 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