Microsoft word - traveller's medical record.doc

TRAVELLER'S MEDICAL RECORD DATE _______________________ FIRST NAME _______________________________SURNAME _______________________________ ADDRESS __________________________________________________________________________ __________________________________________________________ POST CODE ______________ DATE OF BIRTH __________________________ Ethnicity _______________________________ TELEPHONE _____________________________ MOBILE PHONE _____________________________ I (FULL NAME)_____________________________________________________ hereby consent to the administration to myself of the vaccines as listed below. YOUR HEALTH 1. Have you travelled to less developed countries before? Did you have any health problems while away? Do you have or have you ever had any medical problems? eg, asthma, chronic bronchitis, diabetes, stomach ulcer, splenectomy, epilepsy, heart disease, depression, schizophrenia, anxiety attacks, mental illness, weakness of immune system, HIV/AIDS, blood clots Have you been in hospital in the last year? Are you taking any medication now? eg: contraceptive pill, antibiotics or do you occasionally take medication? eg: migraine tablets, ventolin, vitamins Do you have any known allergies? eg: sulphur drugs, eggs, nuts, penicillin, bee stings, iodine, neomycin, latex, band aids? Women only: Are you pregnant or is it a possibility on your return? Please list any past vaccinations and date/year of administration: 10. Do you have any particular health concerns regarding this trip? YOUR TRIP 11. Please list in order the countries you intend visiting, and how long you plan to spend in each: 12. What is the main purpose of your trip? (Please circle) __________________________________________________________________ 13. Type of Accommodation? (Please tick) Other ________________________________________________________________ Other ________________________________________________________________ z:forms/traveller’s medical record 12-2012 PRE-TRAVEL WORKSHEET (to be completed by Medical Staff) Vaccine One injection, booster at 12 months will provide immunity up to 10 years Course of three injections. 0, 1 and 6 months. Course of three injections one month apart. Life long immunity. Two injections. 1, 28 days after first injection One injection if had childhood immunisation. Booster every 10 Three injections. 0, 7, 28 days. Booster at one year. Give one injection if more than 10 years since previous booster Booster six months. Revaccinate against Typhoid every three Recommended Vaccinations [Please tick the vaccinations you wish to have and total the cost] RECOMMENDED MALARIA PROPHYLAXIS / ORAL MEDS . I have been informed of the following: The procedure to follow in the case of an adverse event I am satisfied that I have received enough information today explaining both the benefits and risks of the vaccines to be administered. Any questions I had have been answered to my satisfaction. I have been informed as to the immunisation. Sheet Prepared by I agree to pay the full cost of the vaccines before administration. PATIENT'S AGREEMENT SIGNATURE ____________________________________________ ____________________________________________ ____________________________________________ z:forms/traveller’s medical record 12-2012

Source: http://www.medicross.co.nz/pdf/Travellers_Medical.pdf