Home Visits « Berinsfield Health Centre

Friends & Family Test

Travel forms- Please book an appointment with the Practice Nurse 6 weeks before travelling and hand in the completed form below so that one of the nurses assesses what the advice you will need.
Name:*
Date of Birth*
Contact number:*
Departure and Return dates:*
Duration of Travel:
Countries to be visited:*
Length of Time in each country (days, weeks, months)*
Purpose of travel: holiday / business / visiting friends & family / charity work*
Type of accommodation: hotel / hostel / camping / family home / back packing*
Are you staying in rural or remote areas more than 24 hours from medical care?*
- Yes
- No
In the past have you had vaccinations at a non NHS / private travel clinic or outside the UK? If YES, please bring the details and dates to your appointment with the nurse.*
Are you allergic to anything?*
For women only: Are you pregnant?
- Yes
- No
Are you planning pregnancy?
Are you breast feeding?
Vaccinations available on the NHS are: • All childhood vaccines, if courses have not been completed • Hepatitis A, a course of 2 doses, 6-12 months apart. The first dose covers for 1 year, a second / booster dose will last for 20+ years • Typhoid - a single dose lasts for 3 years • Diptheria, tetanus and polio, boosters are advised every 10 years in certain circumstances • Cholera The following vaccines are administered on a private basis only as they are not provided by the NHS: • Hepatitis B • Yellow fever
Name
This field is for validation purposes and should be left unchanged.

	Very easy	Fairly easy	Not very easy	Very difficult	N/A
Getting through on the phone
Speaking to a doctor on the phone
Speaking to a nurse on the phone
Obtaining test results by phone

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously