Travel Vaccinations Assessment Form September 2012 by 37p5jxgU

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									             TRAVEL HEALTH ASSESSMENT FORM

           Patient to complete and return to Surgery

Name:                                                        DOB

Address:




Tel Nos: Home                             If you are unavailable. May we leave a message?     Yes/No

         Work

         Mobile

Date of Travel - note if within next      Length of Stay
month we may not be able to advise
you.



Countries to be visited:       Rural/City - please give exact locations as health risks may vary within
                               a country e.g. malaria.




Accommodation type - please tick most appropriate

Quality Hotel with good facilities

Basic Hotel with risk of poorer hygiene

Camping/Backpacking

Will you be living or working closely with member of the local population? Y/N

Current Medical Problems/Medications taken/Allergies

								
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