MEADOWCROFT SURGERY: IMMUNISATION FOR FOREIGN TRAVEL
PLEASE NOTE : THERE ARE CHARGES MADE FOR CERTAIN VACCINES AND PAYMENT IS
EXPECTED AT THE TIME OF IMMUNISATION (by cash or cheque with Guarantee Card)
For prices of immunisations see overleaf down Right hand side of sheet
Please phone the surgery to obtain vaccine information 48hrs after you have handed
this form in (please call between 2-4.30pm)
PLEASE ATTEND FOR VACCINATIONS AT LEAST 10 DAYS BEFORE DEPARTURE
IN SOME CIRCUMSTANCES VACCINES COURSES MAY REQUIRE LONGER PERIODS OF TIME
TODAY'S DATE : …………………………………………………………………………… FULL NAME : ………………………………………………………………………………………………………………………………………. ADDRESS : ……………………………………………….………………………………………………………………………………………… CONTACT TELEPHONE NUMBER…………………………………………………………………………………………… DATE OF BIRTH : ……………………………………………………. AGE : ………………………………………………………… DATE OF DEPARTURE : ……………………………………………………………………………………………………………………. LENGTH OF STAY : …………………………………………………………………………………………………………………………… DESTINATION(S) : (COUNTRY & RESORTS) …………………………………………………………………………… IS THERE A STOPOVER? IF SO WHERE? : ………………………… FOR HOW LONG? :……………. ARE YOU BACK PACKING THROUGH OR VISITING RURAL AREAS? : (DETAILS)………. …………………………………………………………………………………………………………………………………………………………………. YOUR HEALTH INFORMATION ARE YOU PREGNANT OR PLANNING TO BECOME PREGNANT? :………………………………………. ARE YOU TAKING ANY MEDICATION? : …………………………………………………………………………………… ARE YOU ALLERGIC TO : DRUGS? ………………… EGGS? ………………… VACCINES? ………………. HAVE YOU RECEIVED RADIOTHERAPY OR CHEMOTHERAPY IN THE LAST 6 MONTHS OR DO YOU HAVE PROBLEMS WITH YOUR IMMUNE SYSTEM? : …………………. HAVE YOU HAD ANY OF THE FOLLOWING IMMUNISATIONS? : TYPHOID (IN THE LAST 3 YEARS) : …………………………………………………………………………………………… TETANUS (IN THE LAST 10 YEARS) : ………………………………………………………………………………………. POLIO (IN THE LAST 10 YEARS) : ………………………………………………………………………………………………. HEPATITIS A : …………………………………………………………………………………………………………………………………… YELLOW FEVER (IN THE LAST 10 YEARS) : ……………………………………………………………………………… MENINGITIS : ……………………………………………………………………………………………………………………………………
TO BE COMPLETED BY NURSING STAFF IMMUNISATIONS REQUIRED
TETANUS/DIPHTHERIA/IPV COMBINED: 1 ………. 2 ………. 3 ………. Booster ……….
TYPHOID : ………………………………………………………………………………………………………………………………….
COMBINED HEP A/TYPHOID COMBINED:………………………………………………………………………………
HEPATITIS B:Planned course:- 0……………….1 month……………….6months……………….
course = £93.00
Accelerated:- 0…………………1 month……………….2 months……………Booster @ 12 months……………
V Accelerated:- 0…………………7 days………………. 21 days……………Booster 12 months
Booster………………………………………………………………………………………………………………………………………………………. £38.00
RABIES : 1…………2…………3……….Booster………….
£181.00
MENINGITIS A C Y W……………………………………………………………………………………………………………………………………………. £42.50 SWINE FLU (H1N1) ……………………………………………………………………………………………………………………………………………. £12.00 JAPANESE ENCEPHALITIS NOT AVAILABLE HERE, PLEASE CONTACT TRAVEL CLINIC ……………………………………………………………………………………………………………………………………………. Bite avoidance advice: Y/N Anti-malarials required: Y/N (if yes please tick appropriately)
Other information : …………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… Date (nurse) __________________ Sign (nurse): _______________________
You are travelling to an area where it is possible to catch malaria. This is a potentially fatal disease spread by mosquitoes. The mosquitoes only bite during the evening and night so avoidance measures need to be used during this period. Protection again mosquitoes •
Insect repellents : apply frequently to exposed skin preparations which contain DEET eg ULTRATHON, AUTAN, JUNGLE GEL (N.B. care with small children) or eucalyptus based repellents such as MOSIGUARD or wear wrist or ankle bands impregnated with repellent. You can also vaporising mats/sprays for clearing rooms of mosquitoes.
Insect barriers : cover arms and legs with clothing in the evening and night. Sleep in screened accommodation and under a pyrethroid impregnated bed net.
Malarial prevention drugs : no tablet will completely prevent malaria but the tablets recommended will provide a useful degree of protection in addition to the above. It is important that you take the full course of tablets starting one or two weeks before travel, throughout your stay and for four weeks after returning (exception Malarone – see below).
If you develop fever or illness, particularly within one year of your return, consult your doctor mentioning your travel to a malarious area.
Recommended drugs in addition to mosquito bite avoidance
Chloroquine (Nivaquine or Avloclor) Buy from a Pharmacist. Two tablets weekly for adults, reduced dose for children. Best taken after food. Start one week prior to travel. Possible side effects : as Chloroquine may produce temporary visual disturbance care should be taken if driving or operating machinery, headache, skin reactions, exacerbate psoriasis, gastro-intestinal disturbances (avoid if history of epilepsy). Not to be taken with Zyban.
Proguanil (Paludrine) Buy from a Pharmacist. Two tablets daily for adults, reduced dose for children, taken at the same time each day. Possible side effects : mild nausea, diarrhoea and mouth ulcers.
Mefloquine (Larium) Private prescription required to purchase tablets at pharmacy. 250mgs per week, three doses prior to travel. Possible side effects : dizziness, nausea, vomiting, diarrhoea, abdominal pain, depression, nightmares, hallucinations, psychosis and convulsions. These occur infrequently and often show within the first three doses. 90% protection against malaria.
Doxycycline : Private prescription. One tablet per day to be taken with a full glass of water sitting upright. Possible side effects : nausea, vomiting, diarrhoea and rash. Photosensitivity : use effective sun screen.
Malarone (Atovaquone / Proguanil) Private prescription. One tablet daily taken with food or milky drink,beginning 24-48 hours before travel to malarious country. Daily during stay (but not longer than 28 days). Continue for 7 days after leaving malarious area. Possible side effects : abdominal pains, headache, anorexia, nausea, vomiting, diarrhoea and coughing.
Do not take if taking Metoclopramide, Tetracycline, Rifampicin or Rifabutin.
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A Recap of the January 28, 2013 Regular Board Meeting At the January 28 Regular Board Meeting, the Volunteer Report Board approved the following routine personnel ac-The Board acknowledged the contributions of more than 150 parent and community volunteers in our schools. Resignations/Retirements Nancy Sue Holland, aide, TEMS, effective Under Priority Discussion