RIVERSIDE COUNSELLING SERVICE DROP IN SESSIONS

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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

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	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