Greens Norton Medical Centre
Travel Consultation Record Card
Date of appointment:
Title:
Mr
Mrs
Miss
Ms
Forename(s):
Surname:
Date of Birth:
Age:
Email Address:
Telephone Number:
Travel Itinery
Date of departure:
Destination(s) and duration of stay:
Type of Holiday:
Holiday
Business
Other
- Details:
Accommodation:
Hotel
Hostel
Family Home etc
High Risk Activities:
Details:
Previous/Current Medical History
Medical History:
Details:
Allergies to drugs or food:
Details:
Current Medication:
Details:
Steroids:
Yes
No
Oral Contraception:
Yes
No
HIV:
Yes
No
Previous reaction to vaccines:
Yes
No
Feels faint with injections:
Yes
No
Previous Vaccination History
(please give dates)
Tetanus
Diptheria
Polio
Typhoid
Hepatitis A 1st or Bst
Hepatitis B 1st, 2nd, 3rd, 4th
Meningitis
Yellow Fever
Other