Branksomewood Healthcare Centre TRAVEL VACCINATION QUESTIONNAIRE PATIENT TO COMPLETE THIS SIDE DOB. GP………………….
DAYTIME CONTACT TEL NO. PLEASE LIST ALL COUNTRIES TO BE VISITED - IN ORDER- INCLUDING STOP-OVERS LENGTH OF STAY
What type of accommodation are you staying in? Hotel / Self -Catering / Backpacking/Cruise Reason for travel? Holiday / Work / Gap Year / Visiting Friends and Family ARE YOU OR DO YOU HAVE ANY OF THE FOLLOWING? :-
HISTORY OF PSYCHIATRIC ILLNESS including anxiety/depression
Have you ever had any of the following vaccinations and if so when? Please bring any records of vaccines you’ve had with you to the appointment. I have answered these questions correctly to the best of my knowledge PATIENT OR PARENT/GUARDIAN SIGNATURE. There is a charge for some vaccines with no exemptions available We are unable to accept credit or debit cards for payment. Payment will be expected on the day of appointment Branksomewood Healthcare Centre TRAVEL VACCINATION QUESTIONNAIRE NURSE TO COMPLETE THIS SIDE REQUIRED TETANUS, DIPHTHERIA & POLIO TYPHOID HEPATITIS A YELLOW FEVER MENINGITIS ACW &Y £50 (2doses orally) HEPATITIS B £35 per injection (initially course of 3 required) £45 per injection (3 Injections per course) JAPANESE £80 per injection ENCEPHALITIS (2 injections per course) TICK-BORNE £65 per injection ENCEPHALITIS (3 injections per course) I give authorisation for practice nursing staff Signature to administer a vaccine or course of any of the above vaccines which are not covered by Hampshire PCT patient group directions MALARIAL PROPHYLAXIS Weight of Child under 16yrs Recommended CHLOROQUINE Buy from chemist PROGUANIL Buy from chemist MALARONE £15.00 for private script + cost of tablets DOXYCYCLINE £15.00 for private script + cost of tablets MEFLOQUINE £15.00 for private script + cost of tablets Insect bite Avoidance Travel Appointment needed? Yes/ No Length of Appointment 10mins/ 20mins/ Not required and appt cancelled Comments---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------
ADVICE GIVEN Food & Water Hygiene Altitude Sickness Yes / No Animal bites Sun and Heat Hepatitis B & HIV Insurance P drive forms travel questionnaire
Liberty Island - Routine Check-Up BRANDON: You've been back with Fringe Division for a week now? OLIVIA: Uh. for eight days. BRANDON: Any headaches or lingering symptoms. mood swings, insomnia? OLIVIA: No. Although I do feel like I keep getting asked the same question over and over again. Is that a lingering symptom? BRANDON: You are recovering from a severe mental break, Agent Dunham-- I h
ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY Introduction 2000 men are diagnosed with prostate cancer every year in Western Australia. Robotic-assisted laparoscopic prostatectomy is performed to treat localised prostate cancer in men with a life expectancy of 10 years or more. The aim is to remove the cancer and prostate completely to achieve cure. What does the procedu