PLEASE COMPLETE PRIOR TO APPOINTMENT WITH DOCTOR
THE FAMILY PRACTICE, STRABANE TRAVEL RISK ASSESSMENT FORM
Please complete this form prior to your travel appointment and return to reception Personal details
Date of birth: Male [ ] Female [ ] Easiest contact telephone number E mail Dates of trip Date of Departure Return date or overall length of trip Itinerary and purpose of visit Country to be visited Length of stay Away from medical help at destination, if so, how remote? Please tick as appropriate below to best describe your trip 1. Type of trip 2. Holiday type 3. Accommodation 4. Travelling 5. Staying in area Urban which is 6. Planned activities Safari
PLEASE COMPLETE PRIOR TO APPOINTMENT WITH DOCTOR
Personal medical history Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions, thymus disorder ) List any current or repeat medications Do you have any allergies for example to eggs, antibiotics, nuts ? Have you ever had a serious reaction to a vaccine given to you before? Does having an injection make you feel feint? Do you or any close family members have epilepsy? Do you have any history or mental illness including depression or anxiety Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Women only: Are you pregnant or planning pregnancy or breast feeding? Have you taken out travel insurance and if you have a medical condition, informed the insurance company about his? Please write below any further information which may be relevant Vaccination History Have you ever had any of the following vaccinations / malaria tablets and if so when? Tetanus
For discussion when risk assessment is performed within your appointment: I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given. Signed __________________________________________ Date ________
PLEASE COMPLETE PRIOR TO APPOINTMENT WITH DOCTOR
For official use Patient Name:
Travel risk assessment performed Yes [ ] No [ ] TRAVEL VACCINES RECOMMENDED FOR THIS TRIP Disease protection Further information
PLEASE COMPLETE PRIOR TO APPOINTMENT WITH DOCTOR
TRAVEL ADVICE AND LEAFLETS GIVEN AS PER TRAVEL PROTOCOL
personal hygiene advice Insect bite prevention
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS Chloroquine and proguanil FUTHER INFORMATION
e.g. weight of child Signed by: Position: Date:
One of the proudest and most significant achievements in Canadian history was the creation of the Cooperative Commonwealth Federation (CCF) in 1933. 2008 marked the 75th anniversary of this event, when unions, farmers, church leaders and aca-demics joined to create for the first time, a Canadian national party of the left. To commemorate, the Canadian Centre for Policy Alternative’s Sask
Home News Blogs Events Points Series | Calendar Gear Training Photos Links Team Yak Team Checkpoint Zero Endures 100 Year Storm in Moab posted Oct 11, 2006 @ 4:32 PM by Paul Cox Just two days after a shortened Adventure Xstream ended in Moab, blue skies in southeastern Utah made it hard to believe teams had just finished racing through what locals were calling a "100