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Appointment – Travel Health Services

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Appointment – Travel Health Services

Appointment – Travel Health ServicesBute Pharmacy2025-03-05T15:06:09+00:00

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*First Name

*Last Name

*Address

*Postcode

*Phone Number

*Email

*Date Of Birth

*Age

*Gender

Male

Female*

*Are you pregnant, breastfeeding or trying to get pregnant?

No

Yes

Where are you travelling to?Please give details of dates travelling, activities planned and accommodation type.

*Please give details

Are you currently taking any prescription medications?

Yes

No

If (yes) please give details

Do you have or have you ever had any allergies or an anaphylactic reaction to a vaccine before?

Yes

No

If (yes) please give details

Have you had a high fever or temperature in the last 24 hours?

Yes

No

If (yes) please give details

Are you immunosuppressed due to disease or treatment?

Yes

No

If (yes) please give details

Do you have any other medical conditions we should be aware of?

Yes

No

If (yes) please give details

Have you ever taken antimalarials before?For example: Malarone (atovaquone/proguanil), Doxycycline

Yes

No

If (yes), did you have any problematic side effects with these? Please state as much detail as possible.

Have you had a kidney failure as a result of malaria or blackwater fever?

Yes

No

Have you ever suffered/do you currently suffer from depression, anxiety, panic attacks or any other psychiatric problems? Please answer yes even if the episode was mild or an isolated case.

Yes

No

If (yes) please give details

Are there any other health/medical details you feel we should know?

Yes

No

If (yes) please give details

Have you had any operations in the last six months?

Yes

No

If (yes) please give details

Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)?

Yes

No

If (yes) please give details

Have you received any live vaccines in the last 4 weeks?

Yes

No

If (yes) please give details

Have you been told by your doctor you have an intolerance to any sugars, (e.g. galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?

Yes

No

If (yes) please give details

Do you have any bone marrow problems or blood disorders (e.g. blood dyscrasias)?

Yes

No

If (yes) please give details

Do you have a known or suspected cancer, or have you had cancer in the past?

Yes

No

If (yes) please give details

Have you received oral or parenteral antibiotics within the last 14 days?

Yes

No

If (yes) please give details

Have you recently had diarrhoea after having an antibiotic medicine?

Yes

No

If (yes) please give details

Have you recently had diarrhoea after having an antibiotic medicine?

Yes

No

If (yes) please give details

Have you previously been infected with dengue?

Yes

No

If (yes) please give details

Have you lived or spent extended periods in a dengue-endemic area?

Yes

No

If (yes) please give details

Do you have any heart rate problems, e.g. arrhythmia or palpitations?

Yes

No

If (yes) please give details

Do you have systemic lupus erythematosus (lupus)?

Yes

No

If (yes) please give details

Are you suffering from constipation, abdominal pain, vomiting or any other digestive problems?

Yes

No

If (yes) please give details

It is our policy to inform your GP when travel vaccinations are provided. Would you like us to send a treatment summary report to your GP?

Yes

No

*Declaration & Consent to TreatmentKindly TICK to confirm that you agree with each of the following statements if you wish to proceed with treatment, then please sign your name below

I have answered all questions truthfully, and I am aware that It is an offence to give false or misleading information about my health.

I consent to being vaccinated for the purposes of travel.

Signature

We are an independent pharmacy with the aim to give the best experience to all of our customers.

CONTACT INFO

01700 502362
info@butepharmacy.co.uk
26 Montague Street, Rothesay

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