TRAVEL ASSESSMENT FORM                         THE THREE SHIRES MEDICAL PRACTICE
Please complete this form prior to your travel appointment and return to reception 

Personal details	

First Name:                                             Surname:	Date of birth:
Male  [  ]    Female  [  ]	
Easiest contact telephone number	
Dates of trip	

Date of Departure……………………………. Return date or overall length of trip……………………………….	
	
Itinerary and purpose of visit	
Country to be visited	Length of stay	Away from medical help at destination, if so, how remote?	
1.			
2.			
3.			

Please tick as appropriate below to best describe your trip
	
1. Type of trip	Business		Pleasure		Other			
2.  Holiday type	Package		Self organised		Backpacking			
	Camping		Cruise ship		Trekking			
3. Accommodation	Hotel		Relatives / family home		Other			
4. Travelling	Alone		With family / friend		In a group			
5. Staying in area which is 	Urban 		Rural		Altitude			
6. Planned activities	Safari
		Adventure		Other			
Personal medical history	
Please list any regular “over the counter” medication you take, that are not on you records here:
	
Have you ever had a serious reaction to a vaccine given to you before? 
	
Does having an injection make you feel faint?
	
Do you have any history or mental illness including depression or anxiety
	
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
	
Women only: Are you pregnant or planning pregnancy or breast feeding?
	
Please write below any further information which may be relevant

	

Vaccination History	
Have you ever had any of the following vaccinations that would not be on your GP records (e.g from Travel Clinics / Abroad? Please gives dates	
Tetanus		Polio		Diphtheria		Typhoid		
Hepatitis A		Hepatitis B		Meningitis		Yellow Fever		
Rabies		Jap B Enceph		Tick Borne				
TB (BCG)		Other		
For discussion when risk assessment is performed within your appointment:
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.  

Patient Signature  __________________________________________  Date ________

For official use
Patient Name:  	

TRAVEL VACCINES RECOMMENDED FOR THIS TRIP  
	
Disease protection	
Yes	
Further information	

Hepatitis A    	

Hepatitis B    	

Typhoid	

Cholera	

Tetanus	

Diphtheria	

Polio	

Meningitis ACWY	

Rabies	

Japanese B Encephalitis	

Yellow Fever	

TB (BCG)	

	
Yellow Fever Vaccination available from :
Box Surgery (01225 742361),  Bath Travel – Sat 8-2pm (01225 820461) , Courtside Surgery (01454 313874 or Christchurch Medical Centre, North St, Downend (0117 970 8950)	

Other	

	

Signed by Nurse…………………………………Signed by GP…………………………………….

TRAVEL ADVICE AND LEAFLETS GIVEN AS PER TRAVEL PROTOCOL

Travel advice leaflet given	
	
Comments	

Travel Record card supplied	

	

MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
Chloroquine and proguanil

Atovaquone + proguanil (Malarone)	

Chloroquine

Mefloquine	

Doxycycline

Malaria advice leaflet given	

Private Prescription Required   or

Dispense Tablets at Surgery	

FUTHER INFORMATION 
e.g. weight of child

Malaria Tabs:	
Private Rx / Dispense 
Done(sig):	

Signed by: Nurse                                                   	
Date:	
	
GP:	
Date:	
Scanned by:

Further Comments

	

THE THREE SHIRES MEDICAL PRACTICE				

THE THREE SHIRES MEDICAL PRACTICE
Colerne, Marshfield, Pucklechurch and Wick Surgeries

Vaccination Prices
Travel consultation with nurse	Free	
Cholera 2 doses	Free	
Diptheria/Tetanus/Polio	Free	
Hepatitis A & Typhoid Combined	Free	
Hepatitis A	Free	
Hepatitis A (Junior)	Free	
Twinrix (Hep A & B)	Free	
Typhoid	Free	
Hepatitis B   3 doses*	£120.00	
Hepatitis B paediatric   3 doses*	£90.00	
Japanese Encephalitis   2 doses*	£180.00	
Meningitis Menveo (ACWY) or Nimenrix	£60.00	
Rabies (Intramuscular)  3 doses*	£180.00	
* Price per course

Malaria Prophylaxis Prices
Medication	pack size	£/pack
inc VAT	£/tablet
inc VAT	
Atovaquone/ proguanil 250/100 adult	12	£24.00	£2.00	
Atovaquone/ proguanil 62.5/25 paediatric	12	£12.00	£1.00	
Lariam	8	£8.00	£3.50	
Paludrine/Avloclor travel pack		£15.00		
Doxycycline 100mg	50	£20.00	40p	

Please allow 4 weeks for general travel and 8 - 10 weeks for long-haul immunisation schedules.
All prices may be subject to change without notice.

Three Shires Medical Practice
January 2016