CONFIDENTIAL TRAVEL VACCINATION QUESTIONNAIRE
For travel ing abroad you may require vaccinations and health advice. Please complete this questionnaire and hand it in at reception. Please telephone after 48 hours to ascertain if a travel consultation is necessary. It is advisable to complete this form 6 – 8 weeks prior to travel ing as multiple appointments may be required. Please complete this form with a black pen DATE___________ NAME ________________________ DATE OF BIRTH _________________ ADDRESS ______________________________________________________ ________________________________TEL NO ________________________ Departure Date ____________ Duration of stay abroad _________________
Type of accommodation __________________________________________________ Please list, in sequence, which countries and regions you plan to visit, including any safaris, jungle expeditions and overland trekking
you plan to do. Are you al ergic to anything? _________________________________________________
Are you pregnant / planning a pregnancy or breastfeeding?_________________________ Do you suffer with any long term medical conditions?______________________________
Are you taking any regular medication (for long term conditions)_____________________
Have you had any of the fol owing vaccinations, including boosters. If so, please indicate the date/s.
Hepatitis A YES / NO ____________ Japanese B Encephelitis YES / NO ___________
Typhoid YES / NO ____________ Hepatitis B YES / NO ____________ Tetanus YES / NO ___________
Yel ow Fever YES / NO ____________ Polio
Rabies YES / NO ____________ Meningococcal YES / NO ___________ TO BE COMPLETED BY NURSE The recommended vaccinations for your travel are circled. If the letter M is present, this means it is mandatory and wil require a certificate of proof of vaccination. Certificate/booklet charge is ₤10.00.
_________________________________________________________________________________________
Hepatitis A Rabies ₤17.00 Prescription charge + Pharmacy fee *Meningococcal Payment of ₤ 45.00 before order. Hepatitis B ₤30.00 *Japanese B Encephalitis Payment of ₤120.00 before order. Yellow Fever ₤55.00 Tetanus/Diphtheria/Polio YES/NO * PAYMENT REQUIRED BEFORE ORDER IS PLACED NO REFUND WILL BE GIVEN ON ORDERED VACCINES Malaria Tablets recommended ₤3.50 PER TABLET.
Lariam or Doxycycline are issued on a private prescription a charge of ₤17.00 applies + pharmacy fees Comments: Please bring the correct money with you or pay by credit card admin fees applies. We NO longer accept cheque payments. We DO NOT keep money on the premises and may not be able to give you change. Reception / Nurse will inform you of the charges. Thank you
Weltwoche Nr. 38, 21. September 2006 Eine Geschichte, die ans Herz geht Von Ralph Pöhner Nach dem Vioxx-Skandal gerät eine weitere Gruppe von Schmerzmitteln unter Verdacht: Erhöht etwa auch Novartis Voltaren das Infarktrisiko In der Medizin redet man von Nebenwirkungen, der Volksmund sagt in solchen Fällen wohl eher: Saupech. Denn derzeit geistert eine wissenschaftliche Studie durc
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