Spørgeskema til rejsevaccinationer

Spørgeskema

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Adresse:                                                                                                                                                               

Postnr./By:                                                                                                                                                          

CPR:                                                                                                                                                                      

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Rejsemål i rækkefølge:                                                                                                                                       

Rejsens/opholdets varighed:                                                                                                                             

Type af rejse:                                                                                                                                                       

Badeferie Treckingferie   Forretningsferie   Udstationering   Andet                                                               

Planer om fremtidige rejser                                                                                                                              

Overståede el. nuværende alvorlige sygdomme: (fjernet milt) Nej   Ja                                                

Tidligere el. nuværende psykiatrisk sygdom Nej   Ja                                                                             

Tidligere el. nuværende epelepsi:   Nej   Ja

Psoreasis: Nej   Ja

Har du æggeallergi   Nej   Ja     Eller anden allergi  Nej   Ja, hvilke(n)                                              

Får du medicin Nej ja, hvilke(n)                                                                                                                

Blodtryk/hjerte/blodfortyndende: Nej Ja                                                                                                

Mavesyre hæmmer Nej Ja

Immundæmpende nu el indenfor 6 mdr Nej   Ja

Har du haft bivirkninger ved tidligere vaccinationer Nej Ja, hvilke(n)                                                 

Har du haft bivirkninger ved tidligere malariaprofylakse Nej Ja, hvilke(n)                                                                

Er du gravid el. planlægger graviditet Nej Ja

Er du fuldt Børnevaccineret Nej Ja

Dato:                                                        Underskrift