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. ………………………………. ………………….
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
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
REJSEBESKRIVELSE ISLAND D. 27/4-10/6 2007 Til alle der kunne have lyst til at tage udenlands og tage en praktik, kan jeg kun sige - gør det!! Jeg har haft en fantastisk oplevelse heroppe på Island, hvor jeg har taget min 6 ugers opvågningspraktik i forbindelse med min intensivuddannelse. Vi fik allerede i forbindelse med vores tilmelding til intensivstudiet tilbudt, at vi kunne tage vor