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Microsoft word - vaxquestionnaire ver01-11.doc

The Portchester Practice, Portchester Health Centre, West Street, PO16 9TU. - Tel: 0844 477 8642. Date Received
Pre-Travel Questionnaire URGENT
(one form to be completed for each person traveling)
Appt booked for ……/……/….… @ …. : ……
Vaccines Ordered

To help us ensure you receive appropriate vaccination(s) and advice prior to your travel
abroad please complete this questionnaire and hand it in before booking an appointment
with the Nurse at least 8 weeks, and preferably 12 weeks, prior to planned date of travel.
PLEASE PRESENT ANY VACCINATION RECORD WITH THIS FORM.
Personal Details:

Full Name: …………………………….…………. Date of Birth: ………./………./……………
Contact Tel. No.: …………………………………. Doctor: ………………………….………….

Travel Details:

Type of Accommodation
Date of Departure: ………./…………/…………….

Countries to be visited
No of days stay Hotel
1. ………………………………. …………………. Hostel
2. ………………………………. ………………….

3. ………………………………. ………………….

4. ………………………………. ………………….

5. ………………………………. ………………….
Please specify ………………………….

Medical History:
I am Allergic to: (tick as appropriate)
Epilepsy?
Antibiotics
Diabetes?
Psoriasis?
Other (please specify) ………………
Heart Disease?
…………………………………………….
Spleen removed?
Respiratory Disease?
I am currently taking the
Mental Health problems/depression? Yes/No
following Medication: ………….….
…………………………………….………. Are you:
……………………………………………… Suffering from a Fever?
If you have ever had a serious reaction
Pregnant/trying to become pregnant?
to a Vaccine please give details ………. H.I.V positive?

On Steroids?
………………………………………….…. Receiving Radio/chemotherapy?

………………………………………………

Declaration.
I believe the information I have given overleaf to be accurate, to the best of my
knowledge, and consent (for my child*) to have the vaccines listed below.
I agree to pay for the Fee Payable vaccinations, by cash or cheque, prior to vaccination
and accept I will be charged 50% of this fee if I miss my appointment.
Name ………………………….……. Signature ……………………… Date ……./……/……….
(patient / parent / guardian*)
* Delete as appropriate.
FOR PRACTICE STAFF USE ONLY

LAST DOSE
VACCINATION
Date of Type S/C/B+
Initials
DIPHTHERIA
Japanese ENCEPHALITIS
Tickborne ENCEPHALITIS
HEPATITIS A
HEPATITIS B
MENINGITIS ACWY
YELLOW FEVER
ANTIMALARIAL TABLETS Prescription:
Total Fee
Chloroquine / Proguanil / Malarone /
Payable: £
Receipt Note
Mefloquine / Doxycycline / Maloprim
Paid ….… (intls) No:
TRAVEL ADVICE LEAFLETS:- ISSUED
Special requirements
Dr’s. Signature ……………………….
Date ………./…….……/……………
+ Doses:- S= Single Dose, C= End of Course/Course, B= Booster. Ver. 01/11

Source: http://www.theportchesterpractice.nhs.uk/website/J82012/files/TravelQuestionnaire.pdf

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PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION PATIENT REGISTRATION IF YOUR CHILD S LAST NAME AND/OR ADDRESS ARE NOT THE SAME AS YOURS, FILL IN THE TOP BOX ALSOPERSON FINANCIALLY RESPONSIBLE FOR ACCOUNTRELATIONSHIP TO PATIENT SOCIAL SECURITY NO. IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR OFFICE? YOU WERE REFERRED TO US BY YOUR FORMER ADDRESS PERSON TO

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