Maryhill Practice Travel Questionnaire

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Travel Clinic
Elgin Health Centre
The travel clinic is held on a Friday afternoon.The clinic is run by nurses who have had
specialist training in travel health issues. Appointments need to be booked beforehand. You
can only be seen at this clinic if you have at least 6 weeks left before travelling. There is no
cost for attending this clinic.
This clinic is for people travelling abroad on holiday.
Nurses are NOT available to give travel advice over the telephone.
Some immunisations for travel abroad are not available on the NHS and there will be a
charge for these. These are listed overleaf.
If you are working abroad you need to access travel advice and immunisations including
prescriptions for antimalarials (if required) through your employer’s occupational health
scheme or from one of the private clinics listed below.
If you are travelling at short notice or do not have 6 weeks left before you travel there are a
number of alternative travel clinics available, these are :
The Travel Clinic ( DON’T SEE CHILDREN UNDER 16)
Go Health Services
Maryhill House
Elgin
01343 567386 ( Mon – Fri )
Private Travel Clinic
Industrial Doctors
Aberdeen
01224 788800 ( Mon – Fri )
The Travel Clinic
GO health Services
Bennachie Building
Royal Cornhill Hospital
Aberdeen
01224 553663 ( clinics Mon - Fri)
RS Occupational Health
10 Lotland St, Inverness,
Inverness-Shire IV1 1PA
01463 513100 (clinics Mon-Fri 8.30am-5.30pm )
MASTA Travel Clinic
Ark Occupational Health
213 George Street
Aberdeen
01224 562747 (clinics most days Mon - Fri )
Up to date travel advice can also be obtained on the Fit For Travel Website
www.fitfortravel.nhs.uk
This site contains lots of useful, up to date advice and resources about travelling abroad.
You will be able to check here what immunisation are required for specific countries.
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Please note however we cannot issue prescriptions for immunisations without seeing you at
the travel clinic.
Travel Vaccines prescribable under the NHS;
Hepatitis A
Typhoid (injectable only, not oral vaccine )
Diptheria/Tetanus/Polio (now only available combined in one vaccine)
Cholera
MMR in those people up to age of 24 years who have not completed the recommended 2
dose schedule.
These are available on a normal prescription .
There is no charge for administering these vaccines.
Travel Vaccines only available on a private prescription;
Meningitis ACW135Y – primary course 1 dose
Japanese Encephalitis- primary course 3 doses
Tick-borne Encephalitis- primary course 3 doses
Rabies – primary course 3 doses
Hepatitis B – primary course 3 doses
MMR – if over 24 years of age – 2 doses
The chemist will charge for the full cost of these vaccines.
There will also be a charge for administration of these vaccinations by the Health Centre.
The cost will be £15 per dose, please note some vaccines require a course of injections ( e.g
Rabies is usually 3 injections so the cost will be 3x £15 = £45)
Payment is required at the time of each injection by cash or cheque, cards are not accepted.
Yellow Fever is only available at registered centres, Elgin Health Centre is one of these.
Cost £ 60.
Anti-malarial medication
If chloroquine and proguanil are recommended, these can be bought at the pharmacy, they
are not available on prescription. This includes children.
If any of the other medications (e.g. Doxycycline, Malarone, Mefloquine ) are
recommended, these are prescribed on a private prescription.
May 2014
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THE MARYHILL PRACTICE
PATIENT QUESTIONNAIRE FOR TRAVEL VACCINATION
Name:
Date of Birth:
M/F
Address:
Date of Departure:
Daytime Tel No:
Countries to be visited
Length of stay
Nature of visit
Accommodation type
Known allergies (Drugs / Foods): ___________________________________________________
Severe reaction to a previous vaccine: _______________________________________________
Previous medical history: _________________________________________________________
Current medical problems: ________________________________________________________
Pregnant:
Yes / No / N/A
Current Medication (including Steroids): ______________________________________________
Oral Contraceptive Pill:
Insurance:
Yes / No / N/A
Yes / No
Vaccine
Tetanus
Diphtheria
Polio
Typhoid
Hepatitis A
Cholera
Yellow Fever
Hepatitis B
Meningitis
Japanese Encephalitis
Rabies
No. of
vaccines in
course
}
} 1
}
1
2
2
1
3
1
3
3
High risk activities:
Admin
Cost per vaccine
Yes / No
Date last
vaccinated
Recommended
vaccinations
}
} Free
}
Free
Free
Free
£60
£15
£15
£15
£15
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Vaccination Schedule
Vaccination required
1st vaccine
Date
2nd vaccine
Date
3rd vaccine
Date
4th vaccine
Date
The above schedule of vaccinations and appointments have been arranged for you. Should you
miss or cancel any of the scheduled appointments we cannot guarantee you will be adequately
protected.
I have no reason to suspect that I am pregnant.
I confirm the answers overleaf are correct to the best of my knowledge and I consent to the above
vaccines being given. I agree to the above schedule and the charge of £15 for administration of
each vaccine on private prescription. The Practice can store your vaccines in their fridges but
these are done so at your own risk.
Signature: _______________________________________ Date: ________________________
Malarial Risk:
Yes / No
No. of tablets required
Chloroquine
Proguanil
Doxycycline
Mefloquine
Malarone
Prescription
No
No
3/12
1/12
Any other information: ____________________________________________________________
______________________________________________________________________________
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