Busby Medical Practice - Patient Services Portal

Pre-Travel Assessment Form

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Title

 
 

Firstname

 
 

Surname

 
 

Date of Birth

 
 

Occupation

 
 
 

Purpose of Trip

 
 
 

Contact Details While Away

Mobile Phone

 
 
 

Daytime Phone

 
 
 

Address

 
 
 

You heard about the travel clinic from?

 
 
 

Travel Agent Name

 
 
 

Travel Agent Address and Contact

 
 
 

Regular General Practitioners Name

 
 
 

Regular General Practitioners Address

 
 
 

Should we send a vaccinations list to your GP?

 
 

My departure date is

 
 
 

My return date is

 
 
 

Itinerary

Country

Duration (weeks)

Accomodation

Cities

x
x
x
x

Please list countries you have visited previously

 
 
 

History / General Health

Is your general health good?

 
 
 

Have you ever fainted or felt unwell soon after an injection?

 
 
 

Could you be pregnant while away? (Females only)

 
 
 

Does someone with lowered immunity live at home with you

 
 
 

Will children be travelling with you?

 
 
 

Are you allergic to eggs, medications or other substances

 
 
 

Please list these allergies

 
 
 

Please list ALL medications you are currently taking

 
 
 

Please list past significant medical / health problems

 
 

Vaccine
Vaccine Table

NB You DO NEED to complete the following table before seeing the doctor.
PLEASE INDICATE WHICH YEAR THE FOLLOWING VACCINES WERE GIVEN.
Also indicate if vou have ever had any of the actual diseases measles, mumps, rubella, chicken pox. You can check with your GP or previous medical records to find this information.


Vaccine

 
 
 

Year


Cholera

 
 
 

Flu vaccine

 
 
 

Hepatitis A immunoglobulin

 
 
 

Hepatitis A vaccine

 
 
 

Hepatitis B

 
 
 

Japanese Encephalitis

 
 
 

Mantoux/BCG

 
 
 

Measles / Mumps / Rubella

 
 
 

Meningococcal

 
 
 

Pink Spot

 
 
 

Pneumovax

 
 
 

Polio

 
 
 

Q fever

 
 
 

Rabies

 
 
 

Tetanus / Diphtheria / Whooping cough(pertussis)

 
 
 

Typhoid

 
 
 

Varicella (chicken pox)

 
 
 

Yellow fever

 
 
 

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