Going Abroad on Holiday Or Business

GOING ABROAD ON HOLIDAY OR BUSINESS

Under the terms and conditions of the NHS,Craiglockhart Medical Group offers a limited travel service, which is sufficient for advice and protection for travelling withinEurope, North America, Australia or New Zealand or single destinations in Africa, Asia and South America.
Please complete the following questionnaire and return it to Reception as soon as possible and at least 6 weeks prior to departure. If less notice is given, we regret that you will be required to attend a private travel clinic.Please contact us after a week to check if vaccinations or malaria tablets are required and make necessary appointments. When giving vaccine history below, please answer ‘don’t know’ rather than leave a blank. Please give us a contact telephone number if possible.

Patients travelling to multiple destinations in Africa, Asia or South America will require more specialised advice, which can be provided at a private travel clinic, a list of which can be obtained from Reception.

NAME: …………………………………...
ADDRESS: ………………………………
……………………………………………..
……………………………………………..
1. Which countries do you intend to visit?
(please specify area and include brief stopovers)
……………………………………………..
……………………………………………..
……………………………………………..
2. Will you be staying in
a)Hotel in tourist area
b)Hotel & Safari
c)Backpacker/Camping
3. Does your journey include
a)Coastal areas
b)Inland areas
4. Do you plan any safaris, jungle exploring or travel in difficult terrain?
……………………………………………
5. Departure Date ………………………
6. Duration of stay abroad …………….
7. Are you likely to travel abroad frequently
………………………. / TELEPHONE NUMBERS:
WORK: ……………………………………
HOME: …………………………………….
DATE OF BIRTH …………………………
8. Have you ever had any of the following vaccinations and, if so, when?
Please estimate
Hep A/Havrix ………………………..
Cholera ………………………..
Typhoid ………………………..
Tetanus ………………………..
Polio ………………………..
Yellow Fever ………………………..
Meningitis ………………………...
Other …………………………
9. Are you or could you be pregnant?
………………………
10. Are you allergic to anything?
……………………….
11. Are you on any medication?
………………………
Please note that some travel immunisations are outwith the NHS and a charge will therefore be made payable on the day of the appointment.
Consent to be signed on the day of the appointment.
I consent/do not consent to the administration of the immunisation(s), the purpose and nature of which has been explained to me.
Signed …………………………………………………………… Date ………………………………….

Patient’s Name …………………………………………………..

VACCINATION SCHEDULEOffice Use Only

Needed for trip? / Date of last vaccine: / Needs to have? / Needed for trip? / Date of last vaccine: / Needs to have?

Diphtheria

/

Rabies

Tetanus

/ Meningitis

Polio

/ Yellow
Fever

Hep A

/ Other:

Typhoid

Hep B

Issue to Discuss

 Malaria prophylaxis

 Bite avoidance

 Hygiene/food/GI upsets

 Items for purchase

 Websites

 Insurance

 Sun safety

 DVT

 Post bite exposure

 HIV/AIDS

Malaria Prophylaxis Options

 Proguanil/Atovaquone (Malarone

 Chloroquine (over the counter)

 Proguanil (over the counter)

 Doxycycline

 Mefloquien (Lariam)

 Bite avoidance only - ABC

Private prescription needed? Yes/No

GP Signature ……………………………………….