Please complete page 1 & 2 prior to your travel appointment and bring all 3 pages to the Travel Nurse. Personal details Name: _____________________________________________________________________________________________________ Date of Birth:
_____________________________________________________________________________________________________ Easiest contact telephone number:
_____________________________________________________________________________________________________
E.mail: _____________________________________________________________________________________________________ GP name and address if not enrolled at this medical practice: _____________________________________________________________________________________________________ Date of Departure…………………………………………… Overall length of trip……………………………….
Itinerary and purpose of visit
Country to be visited
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1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________ 4. _____________________________________________________________________________________________________ 5. _____________________________________________________________________________________________________ 6. _____________________________________________________________________________________________________ Please circle the descriptions that best describe your trip 1.
_____________________________________________________________________________________________________ 2.
_____________________________________________________________________________________________________ 3.
Other……………………………….
_____________________________________________________________________________________________________ 4.
_____________________________________________________________________________________________________ 5.
_____________________________________________________________________________________________________ 6.
_____________________________________________________________________________________________________ Personal medical history Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder. _____________________________________________________________________________________________________ List any current or repeat medications. _____________________________________________________________________________________________________ Do you have any allergies, for example to eggs, antibiotics, nuts? Patient Name: Date of Birth:
Have you ever had a serious reaction to a vaccine given to you before? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Does having an injection make you feel faint? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Do you or any close family members have epilepsy? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Do you have any history of 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? If you have a medical condition, have you informed the insurance company about this? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Please give any further information that may be relevant, including any future travel plans. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Vaccination history
Have you ever had any of the following vaccinations/malaria tablets, and if so, when?
_____________________________________________________________________________________________________
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_____________________________________________________________________________________________________ Other _____________________________________________________________________________________________________ Malaria tablets _____________________________________________________________________________________________________ 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:
For official use
Travel risk assessment performed Yes [ ] No [ ] Authorisation for Nurse to administer vaccination.
Signed…………………………………………………………………….
_____________________________________________________________________________________________________ Travel vaccines recommended for this trip Disease protection Recommended Further information
Hepatitis A _____________________________________________________________________________________________________ Hepatitis B _____________________________________________________________________________________________________ Typhoid _____________________________________________________________________________________________________ Cholera _____________________________________________________________________________________________________ Tetanus/Diptheria _____________________________________________________________________________________________________ MMR _____________________________________________________________________________________________________ Polio _____________________________________________________________________________________________________ Meningitis ACWY _____________________________________________________________________________________________________ Yellow Fever _____________________________________________________________________________________________________ Rabies _____________________________________________________________________________________________________ Japanese B Encephalitis _____________________________________________________________________________________________________
Other Travel Record card supplied _____________________________________________________________________________________________________ Travel advice and/or leaflets given as per travel protocol
Food, water and personal hygiene advice Travellers diarrhoea Hepatitis B, C and HIV _____________________________________________________________________________________________________
Insect bite prevention Rabies Accidents Insurance Air travel _____________________________________________________________________________________________________
Sun and heat protection Hajj travel Yellow Fever Blood borne virus _____________________________________________________________________________________________________
Global Traveller Checklist Malaria Altitude sickness Cruise ship travel _____________________________________________________________________________________________________
_____________________________________________________________________________________________________ Malaria prevention advice and malaria chemoprophylaxis
Atovaquone + proguanil (Malarone) Chloroquine Mefloquine Doxycycline _____________________________________________________________________________________________________ Further information e.g. weight of child Signed by:
O ABORTO E SEUS SIGNIFICADOS DE RESISTÊNCIA Gilberta Santos Soares1 Há muito venho pensando sobre como a decisão de uma mulher de interromper uma gravidez não planejada pode conter um profundo sentido de resistência das mulheres às imposições sociais que regem comportamentos, práticas sexuais e desejos impostos a partir dos códigos dominantes nas relações de gênero. O con
Purchasing for Pollution Prevention Lindane-Free Scabies Prevention and Treatment Scabies are caused by a parasite, sarcoptes scabiei var. hominis, also known as the itch mite. The disease is transmittedthrough direct contact with an infected person, or from contact with infested bedding or clothing. Scabies are mostcommon among children and people living in institutional settings or crowded
