P L E A S E N O T E - There will be a charge for each person, even if your travel has been discussed previously with your own GP.
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1 I M P O R T A N T - It is preferable that your Travel Consultation appointment is made one month prior to your departure. Please return this record this form promptly. You will be advised of an appointment time and date. P L E A S E N O T E - There will be a charge for each person, even if your travel has been discussed previously with your own GP. 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. CLINICAL (DR & RN) GUIDELINES - URGENT CARE, Version 1, Expires 30 June 2019, Page 1 of 5
2 YOUR HEALTH 1. Have you travelled to less developed countries before? Yes / No Did you have any health problems while away? Yes / No If yes, please specify Do you have or have you ever had any medical problems? eg, asthma, blood clots, cancers, chronic bronchitis, anxiety attacks or depression, diabetes, epilepsy, heart disease, HIV/AIDs, mental illness, stomach ulcer, splenectomy, schizophrenia, weakness of immune system, Yes / No If yes, please specify Have you been in hospital in the last year? Yes / No 4. Have you had a blood transfusion? Yes / No 5. Have you ever had hepatitis? Yes / No 6. Are you taking any medication now? eg: contraceptive pill, antibiotics or do you occasionally take medication? eg: migraine tablets, ventolin, vitamins Yes / No If yes, please specify Do you have any known allergies? e.g. : sulphur drugs, eggs, nuts, penicillin, bee stings, iodine, neomycin, latex, band aids? Yes / No If yes, please specify Women only: Are you pregnant or is it a possibility on your return? Yes / No 9. Please list any past vaccinations and date/year of administration: BCG Diphtheria/Tetanus Typhoid Hep A Hep B Meningitis Influenza MMR Rabies Polio Yellow Fever Other Do you have any particular health concerns regarding this trip? Yes /No Please outline... CLINICAL (DR & RN) GUIDELINES - URGENT CARE, Version 1, Expires 30 June 2019, Page 2 of 5
3 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) Holiday Visiting family/friends Business Trip Other 13. Type of Accommodation? (Please tick) Camping Budget Air Conditioned Hotel Private Home Other 14. Planned activities? (Please tick) Trekking / Altitude Scuba Diving Cycling Rafting / Boating Other 15. Date leaving New Zealand Date returning to New Zealand CLINICAL (DR & RN) GUIDELINES - URGENT CARE, Version 1, Expires 30 June 2019, Page 3 of 5
4 PRE-TRAVEL WORKSHEET (to be discussed with Medical Staff) Vaccine : Number of Doses Required. Please tick the vaccinations you wish to have. 1. Hepatitis A One injection, booster at 12 months will provide immunity up to 10 years 2. Hepatitis A & B Course of three injections. 0, 1 and 6 months. 3. Hepatitis B Course of three injections one month apart. Life long immunity. 4. Japanese Encephalitis Two injections. 1, 28 days after first injection 5. Meningococcal ACYW135 (Menectra) One injection. Booster at 3 years. 6. Polio One injection if had childhood immunisation. Booster every 10 years. 7. Rabies Three injections. 0, 7, 28 days. Booster at one year. 8. Tetanus - Give one injection if more than 10 years since previous booster dose. 9. Typhoid One injection. OR 3 capsules taken on Day 1, day 3 and day 5 -Three yearly booster. 10. Hepatitis A / Typhoid Booster six months. Revaccinate against Typhoid every three years. 11. Cholera - Two sachets taken 1 week apart - Booster if needed at 2 years. 12. Yellow Fever - One injection - life long immunity 13. Other -e.g. Influenza, pneumococcal, tick borne encephalitis... RECOMMENDED MALARIA PROPHYLAXIS / ORAL MEDS..... I have been informed of the following: The vaccines being given today The care after vaccination The risks of vaccination The possible side effects 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. CLINICAL (DR & RN) GUIDELINES - URGENT CARE, Version 1, Expires 30 June 2019, Page 4 of 5
5 Sheet Prepared by... Nurse Sheet Prepared by... Doctor Date... I agree to pay the full cost of the vaccines before administration. PATIENT'S SIGNATURE Date CLINICAL (DR & RN) GUIDELINES - URGENT CARE, Version 1, Expires 30 June 2019, Page 5 of 5
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