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YELLOW FEVER IMMUNISATION
\par }\pard\plain \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 
\b\insrsid5596859 
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\par 
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\insrsid5596859 You should be immunised against yellow fever before you travel to
\par certain countries. Check with your practice nurse at least three weeks 
\par before you travel to see if you need this immunisation.
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 
\par What is Yellow fever?
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 Yellow fever is a serious disease with
 symptoms of high fever, vomiting, jaundice and bleeding. It is often fatal and there is no cure. Yellow fever is caused by a virus. It is passed to humans by bites from infected mosquitoes, which tend to bite during daylight hours. (This is different to 
the mosquitoes that carry malaria, which tend to bite from dusk to dawn). Yellow fever occurs in certain countries of Africa and {\*\xmlopen\xmlns2{\factoidname place}}South America{\*\xmlclose}
. Preventative measures include protection from mosquito bites and immunisation.
\par 
\par }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Who should be immunised against yellow fever?
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 \'b7  }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Travellers}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
 to countries where yellow fever is a risk. Some countries require a certificate of immunisation against yellow fever before they will let you into the country. Yellow fever is the only disease which routinely requires proof of immunisation.
\par      \'b0\tab In some countries immunisation is compulsory for all incoming visitors. 
\par      \'b0    \tab In some countries immunisation is compulsory for those who have travelled 
\par }\pard \ltrpar\ql \fi720\li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 from a \lquote yellow fever\rquote  area or country.
\par }\pard \ltrpar\ql \fi-420\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 \'b0 \tab Your doctor or practice nurse c
an advise if you should be immunised for your travel destination and whether you need a certificate of immunisation.
\par 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 The vaccine and where can I get it?
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 You should have an injection of vaccine at least ten days before the date of travel to allow immunity 
to develop. A single dose of vaccine provides immunity for at least ten years, maybe even for life. However, a booster dose (and a repeat certificate of immunisation) is recommended every ten years if you are still at risk.
\par 
\par The vaccine stimulates your body to make antibodies against the yellow fever virus. These antibodies protect you from illness should you become infected with this virus.
\par 
\par }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Are there any possible side effects from the vaccine?
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859      \'b0\tab 5-10% of people may experience a mild headache, muscle aches, mild fever or soreness at the injection site five to ten days after the immunisation.
\par      \'b0\tab Immediate allergic reactions such as urticaria (nettle type rash) and anaphylaxis are rare.
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par }\pard\plain \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs24\alang1025 \ltrch\fcs0 \b\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid5596859 Please read the following contraindications to this vaccine and circle
\par  \lquote yes\rquote  or \lquote no\rquote , whichever applies.
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 
\b\insrsid5596859 
\par Who should not receive the yellow fever vaccine?\tab 
\par      }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 \'b0\tab Current treatment for cancer with chemotherapy, generalised 
\par \tab radiotherapy or within six months of finishing such treatment.\tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab Patients on immunosuppressive treatment after an organ 
\par }\pard \ltrpar\ql \fi720\li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 transplant.\tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 
Yes/No
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859      \'b0\tab Bone marrow transplant in the last six months.\tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 
\b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab Taking steroid tablets (Prednisolone) either long term or
\par \tab on a current short course of high dose steroids.\tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab HIV positive or you have another immune deficiency syndrome.\tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859      \'b0\tab You are currently suffering from a febrile illness.\tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab You are currently pregnant.\tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab You have lymphoma, leukaemia or Hodgkin\rquote s disease.\tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab Severe anaphylactic reaction to eggs.\tab \tab \tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab Allergic to polymyxin or neomycin.\tab \tab \tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab The patient is a child under nine months of age.\tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab You have a thymus disorder, including myasthenia gravis,
\par \tab thymoma thymectomy, Di George syndrome.\tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par 
\par }\pard\plain \ltrpar\s1\ql \li0\ri0\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs24\alang1025 \ltrch\fcs0 \b\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid5596859 Special Precautions
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
     \'b0\tab Are you over 60 years of age.\tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par      \'b0\tab Is the patient a breast fed infant.\tab \tab \tab \tab \tab }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\insrsid5596859 Yes/No}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 
\par 
\par 
\par I have read the yellow fever information sheet and all the contraindications and none of these apply to me.
\par 
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\ltrch\fcs0 \insrsid5596859 Signature\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85
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\par I am not allergic to eggs, polymyxin or neomycin.
\par 
\par }\pard\plain \ltrpar\s1\ql \li0\ri0\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs24\alang1025 \ltrch\fcs0 \b\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid5596859 Signature\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5596859 

\par The nurse will assess your particular need for the yellow
 fever vaccine after taking into account your travel destination, your medical history and your current medication. She will discuss fully any potential side effects and concerns you may have before proceeding with the immunisation.
\par 
\par 
\par 
\par }\pard\plain \ltrpar\s16\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs24\alang1025 \ltrch\fcs0 \b\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid5596859 Thank you for reading and completing this form.
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\par   
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