Our Practice nurses offer advice, information and vaccinations for those travelling abroad.

It often takes several weeks for all recommended immunisation courses to be given. We therefore strongly advise that you to see our nurse at our Travel Clinic or attend one of the undernoted Travel ClinicsAT LEAST 12 WEEKS BEFORE YOUR DEPARTURE DATE.

We provide:

Advice on which vaccinations are recommended or required.

General travel health advice.

Administration of vaccinations available on the NHS.

We do not provide non NHS vaccinations such as Meningitis, Hepatitis B, Yellow Fever, Rabies, Japanese B Encephalitis or Tick Borne Encephalitis. If you think you may require these, or if the nurse recommends them, you will be advised to attend one of the specialist travel clinics.

Please fill this in as much as you can, on the next page only, and hand it in to reception. You will be given an appointment once the completed questionnaire is received. At your appointment, the nurse will go over the questionnaire, decide which vaccinations you need and administer any required vaccines. You will also be told if you need further appointments and whether you need to need to attend one of the specialist travel clinics.

This form muse be filled in and handed into reception before an appointment can be made for you with the Practice Nurse.

Full name /
Date of birth
Address
(including Postcode)
Telephone number
Destination(s) / Date of arrival / Date of departure
1.
2.
3.
Type of travel
(please tick any/all that apply) / Type of accommodation
(please tick any/all that apply)
Holiday / Hotel / House/villa
Business Trip / Chalet / Backpacker Hostel
Visiting cities only / Camping
Have you any sports or adventure activities planned?
Yes / If yes, please state which ones / No
Do you have any allergies?
Yes / If yes, please state which ones / No
Do you have any significant past or current medical problems?
Yes / If yes, please state / No
Are you currently taking any medication?
Yes / If yes, please list / No
Female patients – are you planning to try for a pregnancy or might you be pregnant?
Yes / No
Practice use only / Patient directed to private clinic for the following?
Vaccine / Cover rec. for current trip? / Vac. therefore required?
(check vaccine history) / Hepatitis B
Yellow Fever
Tick borne Encephalitis
Tetanus / Japanese Encephalitis
Diphtheria / Rabies
Polio / Meningitis
Typhoid / BCG
Hepatitis A
Cholera
6 to 12 month booster advised?
Malaria
Is there a risk of Malaria? / Yes / No
Awareness, understanding of how it is contracted, symptoms / Yes / No
Bite avoidance (nets, repellents, etc.) / Yes / No
Signs, symptoms, diagnosis / Yes / No
Written info. Given to patient / Yes / No
Written or verbal information given
Food and water / Written / Discussed / DVT prevention / Written / Discussed
Insect bites / Written / Discussed / Safe sex and contraception / Written / Discussed
Accidents / Written / Discussed / Fit for Travel web address / Written / Discussed
Health Insurance / Written / Discussed / Contact details for private travel clinics / Written / Discussed
Safe sun / Written / Discussed / Other
(please specify below) / Written / Discussed
Other
Private Clinic
Advised to attend private clinic for further advice, vaccines or anti malarials / Yes / No
Further information (if applicable)
Assessor’s signature / Date