TRAVEL CLINIC RECORD CARD
Name:
Age:
Country to
be visited
D.O.B
M/F
Tel No:
Area of
Departure
country
date
TRAVEL CLINIC RECORD CARD
APPT
Name:
Length of
stay
Age:
Country to
be visited
Nature of
visit
Circle all those that apply:
Hotel
Accommodation:
Business
Reason:
Coast
Visiting:
Alone
Companions:
Known Allergies (drugs/food):
D.O.B
M/F
Tel No:
Area of
Departure
country
date
APPT
Length of
stay
Nature of
visit
Circle all those that apply:
Private Home
Pleasure
Interior
Partner
Back-Packing
Voluntary Service
Island
Group
Hotel
Accommodation:
Business
Reason:
Coast
Visiting:
Alone
Companions:
Known Allergies (drugs/food):
Private Home
Pleasure
Interior
Partner
Back-Packing
Voluntary Service
Island
Group
Reaction to previous vaccine (eg fainting):
Reaction to previous vaccine (eg fainting):
Previous medical conditions:
Previous medical conditions:
Current medical problems:
Current medical problems:
Current medication:
Current medication:
Fit & Well today? Yes/ No
Pregnant or planning pregnancy? Yes/ No
Previous Vaccine History (date)
Polio
Typhoid
Rabies
Tetanus
Hepatitis B
Other
Diptheria
Hepatitis A
Meningitis
Yellow Fever
Please state a DAY TIME contact number – this is ESSENTIAL.
If you have a travel vaccination record card please bring this with you to
your appointment. Please read the Pricing Schedule carefully – some vaccines
are not free on the NHS – there will be a charge.
Fit & Well today? Yes/ No
Pregnant or planning pregnancy? Yes/ No
Previous Vaccine History (date)
Polio
Typhoid
Rabies
Tetanus
Hepatitis B
Other
Diptheria
Hepatitis A
Meningitis
Yellow Fever
Please state a DAY TIME contact number – this is ESSENTIAL.
If you have a travel vaccination record card please bring this with you to
your appointment. Please read the Pricing Schedule carefully – some vaccines
are not free on the NHS – there will be a charge.
I confirm that the above answers are correct to the best of my knowledge. I
consent to the above vaccines being given. Signature:
I confirm that the above answers are correct to the best of my knowledge. I
consent to the above vaccines being given. Signature:
Date:
Date:
Recomme
nded
Vaccine
Batch No.
Tetanus/Low dose
Diphtheria
Polio
Typhoid
Hepatitis A 1st
dose
Hepatitis A
Booster dose
Yellow Fever
Meningitis
Hep B or A&B 1st
Hep B or A&B 2nd
Hep B or A&B 3rd
Hep B 4th
Other
Date given
Site
Initials
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
Malaria – Chemoprophylaxis advised
yes/not required
Leaflet given
yes/no
Drugs recommended: Chloroquine/Proguanil/Mefloquine/
Doxycycline/Malarone
Signature:………………………..
Date……………..
Travel Clinic
1. Please ensure you collect a Travel Information Pack from Reception and
read though this information prior to your appointment with the Travel
Nurse.
2. You MUST specify ALL of your holiday/ travel destinations on the
Record Card, the countries and the Cities/ Towns etc., which you intend
to visit. Please also include the number of days/ weeks at each destination.
3. Please state the number of night in each area – this is important for the
nurse to calculate the number of Malaria tablets you may require.
4. If any details change between completing this card and your attendance at
the clinic – let us know as soon as possible.
Recomme
nded
Vaccine
Batch No.
Tetanus/Low dose
Diphtheria
Polio
Typhoid
Hepatitis A 1st
dose
Hepatitis A
Booster dose
Yellow Fever
Meningitis
Hep B or A&B 1st
Hep B or A&B 2nd
Hep B or A&B 3rd
Hep B 4th
Other
Date given
Site
Initials
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
R
L
Arm Leg
Malaria – Chemoprophylaxis advised
yes/not required
Leaflet given
yes/no
Drugs recommended: Chloroquine/Proguanil/Mefloquine/
Doxycycline/Malarone
Signature…………………………..
Date……………………
Travel Clinic
1 Please ensure you collect a Travel Information Pack from Reception and
read though this information prior to your appointment with the Travel
Nurse.
2 You MUST specify ALL of your holiday/ travel destinations on the
Record Card, the countries and the Cities/ Towns etc., which you intend
to visit. Please also include the number of days/ weeks at each destination.
3 Please state the number of night in each area – this is important for the
nurse to calculate the number of Malaria tablets you may require.
4 If any details change between completing this card and your attendance at
the clinic – let us know as soon as possible.