COMPLETE TRAVEL CONSULTATION FORM AND POST, UPLOAD, OR BRING TO STUDENT HEALTH
Name: Click or tap here to enter text. Dob: Click or tap to enter a date. Tel. no. Click or tap here to enter text.
PATIENT DETAILS: Please enter details of childhood/travel vaccines/medical history/medication/allergies
What vaccines have you had?: Click or tap here to enter text.
Current illnesses OR Medical History of Note: Click or tap here to enter text.
Current medication: Click or tap here to enter text.
Allergies OR Anaphylaxis: Click or tap here to enter text.	Pregnant:☐ Breastfeeding:☐
TRAVEL DETAILS: Please enter the details of your trip- When, Where, and for how long are you going?
Date of departure: Click or tap to enter a date. Total duration of stay:Click or tap here to enter text.
Destination(s) in order: Click or tap here to enter text.
Type of trip: Choose an item. Areas to be visited : Choose an item. >3000m ☐ Malarial area? ☐
PLESE READ TRAVEL HEALTH WEBSITES TO LEARN OF HEALTH RISKS e.g. www.fitfortravel.nhs.uk
THE TABLE BELOW WILL BE COMPLETED BY STUDENT HEALTH AT YOUR TRAVEL CONSULTATION
Vaccinations recommended for ALL travellers
Illness	Vaccine Name (route)	No. of doses	Cost per course	Schedule: interval btw doses (days)	Prescribe Yes No	Date(s) Given/Initials	Booster Due
Diphtheria Tetanus Polio (Pertussis)	Revaxis or (IPVBoostrix ) (i.m)	1	35 (40)	0	10yrs +
Typhoid	Typhim (i.m)	1	35	0	3 yrs
Hepatitis A Hepatitis B	Twinrix (i.m)	3 or (4)	165 (220)	0,7,21,365 0,30,60,365	lifelong
Vaccinations recommended for CERTAIN travellers based on Risk Assessment
Illness	Vaccine Name (Route admin)	No. of doses	Cost per course	Schedule: interval btw doses (days)	Prescribe Yes No	Date(s) Given/Initials	Booster Due
Rabies	intra.muscle intra.dermal.	3	210 105	0,7,21/28	5+ yrs
Hepatitis A Typhoid	Viatim or Hepatyrix (i.m)	1	50	0	HAV 6-12M Typh 3yrs
Yellow* Fever	Stamaril (Deep s.c.)	1	40	0	*Certificate Required	lifelong
Meningococcal	ACWY* (Deep s.c.)	1	60	0	* Named pt	5 yrs
Cholera	Dukoral (Oral)	2	50	0,7 (up to 42)	2 yrs
Measles Mumps Rubella	MMR Vax PRO i.m)	1	Free	0	lifelong
Hepatitis B	Engerix B	3 or (4)	120 (160)	0,7,21,365 0,30,60,365	lifelong
Hepatitis A	Avaxim Havarix	1	40	6-12 M
Medication Recommended for Malarial Prophylaxis – depends on destination, side effect profile and costs
Medication	DOXYCYCLINE*	MALARONE
Side Effects	(Relatively common. Not usually serious) N/V/Diarrhoea/Dysp/Thrush/Sunburn++	(Relatively rare. Not usually serious) N/V/Diarrhoea/Headache/Deprn/Nmares
Dosage	1/day.Begin 2 days before until 4 wks after	1/day.Begin 2 days before until 7 days after

* A trial dose of Doxycycline is recommended 2-3 weeks pre-departure, to determine if tolerable and to ensure no significant side effects occur.

** Approximate cost only. Discuss with Pharmacist. Note all anti-malarial medication is available to full Medical Card holders for Prescription Charge only.