Beacon Medical Practice Pre-Travel Questionnaire 1
It is essential that you visit our Travel Clinic well in advance of travelling abroad. Our Nurse will be able to advise you personallyregarding vaccinations, malaria prevention and general health issues you should consider for your destination. To help you have all the right information at hand, print off this form, complete the details, and hand it in at Reception at your earli-est convenience but preferably before you attend for your travel health consultation. Personal details Dates of trip Details about destination(s)
Country and location to be visited
Away from medical help at destination, ifso, how remote?
Please tick as appropriate below to best describe your trip Personal medical history - please tick below if it applies to you Women only: Pregnant List of current or repeat medication, including contraceptive pill Malaria medication history Have you previously taken any of the following malaria medication:
Other / Can’t remember but I travelled to:
When you took the malaria medication: Vaccination history Have you ever had any of the following vaccinations and if so when:
Do you feel faint when having an injection
Beacon Medical Practice Pre-Travel Questionnaire 2 Before you travel remember
A dental check-up now may prevent problems on your travels.
Make sure you have enough of any current medication to see you through the trip. This might include oral contraceptive pills,inhalers, etc.
Get the right travel health insurance for your destination and the activities you’re planning to take part in. You will need to de-clare any pre-existing medical condition in order to get the correct cover. An European Health Insurance Card (EHIC) entitlesyou to free or reduced rate medical care in most EU countries. You can apply for one online (www.dh.gov.uk), by phone (0845606 2030) or by post using a form from the Post Office. N.B. The EHIC is not a substitute for adequate holiday insurance.
Pack a first aid kit (a sterile kit of emergency equipment may be a good idea if you are going somewhere remote).
Find out about the region you are travelling to. The Foreign Office website contains information and advice on travel abroad,and advice on specific risks in specific countries (www.fco.gov.uk).
If you are suffering from fever or infection you should inform your health professional on the day you visit for your vaccinations. Your consent
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 recom-mended and have had the opportunity to ask questions. I consent to the vaccines being given.
Signed: ……………………………. Parent/guardian (if child): ………………………………. Date: …………………. FOR OFFICIAL USE
Travel risk assessment performed: Yes No
Travel vaccines recommended for this trip Travel advice and leaflets given as per travel protocol
Food, water & personal hygiene advice
Blood and bodily fluids infection risk, e.g. Hepatitis B
Malaria prevention advice and malaria chemoprophylaxis Other information
*) If you tick the “Yes” box, you confirm that you give permission for Beacon Medical Practice to send SMS messages to the mobile number above for the purpose ofconfirming booked appointments, reminding you of an appointment and informing you of important information regarding Beacon Medical Practice.
Major languages: French, indigenous languages Major religions: Indigenous beliefs, Islam, Christianity Life expectancy: 47 years (men), 48 years (women) (UN) Monetary unit: 1 CFA (Communaute Financiere Africaine) franc = 100 centimes Main exports: Cotton, animal products, gold GNI per capita: US $400 (World Bank, 2006) Direction du Tourisme et de lHôtellerie BP 624, Ouagadougou 01, Bu
Release Of Information-Hospital Notes Report Period from 01/01/2001 thru 01/01/2006 Test Patient Date of Birth: 11/30/29 Medical Record: 123456 Patient, Test 123456-1 Discharge Summary Confidential Report Run on: Thu Jun 18 09:18:51 CDT 2009 by Release Of Information-Hospital Notes Report Period from 01/01/2001 thru 01/01/2006 Test Patient Date of Birth: 11/30/29