It would help us greatly if you had some awareness of the travel health problems that you may be at risk from on your trip before you come for your appointment.
Before you attend your appointment please go to the following website www.fitfortravel.nhs.uk and read the information for the country you are visiting.

Travel advice and the following vaccines are provided free at South Queensferry Medical Practice:

·  Tetanus, Diphtheria, Polio

·  Hepatitis A

·  Typhoid

Specialist advice and other vaccines are available at the travel clinics below:

·  Western General Hospital, The Travel Clinic, Ward 41, Crewe Road South, Edinburgh, EH4 2XU - 0131 537 2822; http://www.nhslothian.scot.nhs.uk/Services/A-Z/RIDU/TravelClinic

·  MASTA Travel, Davidsons Mains Medical Centre, 5 Quality Street, Edinburgh, EH4 5BP 0131 336 3038; http://www.davidsonsmainsmedicalcentre.scot.nhs.uk/edinburgh-travel-clinic,59636.htm

·  Barnton Pharmacy Travel Clinic, 195 Whitehouse Road, Edinburgh, EH4 6BU

0131 339 3449; http://mybarntonpharmacy.co.uk/services/pharmacy-travel-clinic

·  Superdrug Travel Clinic, 83 Princes Street, Edinburgh, EH2 2ER – 03 333 111 007

https://onlinedoctor.superdrug.com/travel/clinic/edinburgh.html

·  Boots - on line service – appointments held at The Gyle after on-line registration only -http://boots.com/travelhealth

Please complete Page 2 of this travel form and hand it into the surgery BEFORE your appointment with a Practice Nurse. A double appointment should be made with a Nurse to discuss any travel vaccinations required.

*** Please give 3 months notice for complex itinerary. ***

*** Please complete vaccine history BEFORE appointment. ***

NB: The surgery does not provide Yellow Fever Vaccination


This form must be completed and handed into the surgery BEFORE practice nurse appointment.

Date form submitted to Practice:

Have you visited www.fitfortravel.nhs.uk ?

/ Y / N
Name:
Address:
Postcode:
Date of Birth:
Telephone Nos: / Home: / Mobile: / Work:
E-mail address:
Date of Departure: / Overall Length of Trip: / (days)
Country(ies) and area(s) within country(ies) visiting– Please list in date order:
Country / Area / Dates (from & to) / Total (days)
1
2
3
4
5
6
Type of holiday (please tick)
Package / Business / Backpacking / Staying with relatives
Cruise / Other (please state):
Previous/Current illness(es) of note:
Have you recently undergone radiotherapy, chemotherapy or steroid treatment? / Yes / No
Women only: Are you pregnant / Yes / No / Planning pregnancy / Yes / No
Breast feeding / Yes / No
Current medication:
Allergies/serious reactions to previous vaccines:

PLEASE COMPLETE BEFORE APPOINTMENT:

Vaccination History / Vaccination Recommendations
I have had the following vaccinations: / To be competed by Nurse
Vaccinations / Date given / Vaccination
Tetanus / Tetanus
Diphtheria / Diphtheria
Polio / Polio
Typhoid / Typhoid
Hepatitis A 1st / Hepatitis A 1st
Hepatitis A 2nd / Hepatitis A 2nd
Other / Other

TO BE COMPLETED BY NURSE:

Malaria Tablets Required

/ Yes / No / Please make double appointment to discuss.