Travel Clinic Questionnaire
Please complete, return and make appointment for the Travel Clinic a
MINIMUM of FOUR weeks prior to travelling
Name:
Date of Birth:
Telephone:
email:
Please list below ALL countries you will visit and the actual city/town/type of area you will stay
in. Please remember to include any stopover stays. Please detail duration of stay in any
particular area.
Date of departure:
Country
1.
2.
3.
4.
City/Town/Area
Length of stay
Please continue on a separate sheet if required
Please circle any of the following which applies to your accommodation/type of holiday:
Hotel/Self Catering
Backpacking
Camping
Safari/trecking
Staying with Relatives
Other (Please Specify)
Please circle any of the following which may apply to you:
Pregnant/Planning Pregnancy
Breast Feeding
Oral steroids
Taking Anti-Cancer Drugs
Taking Antiretroviral Drugs
Immunity problems
Reaction to Previous Vaccination
Allergies
Please circle any of the following that apply to you:
Mental Health Problem
Epilepsy
Psoriasis
Please give details if you can recall having any of the following vaccinations in the past, no
matter how long ago. To jog your memory vaccinations may have been given at school, in the
armed forces, in Accident & Emergency Departments or prior to foreign travel.
Tetanus:
Polio:
Diphtheria
Hepatitis A:
Typhoid:
Other:
Date
Date
Date
Date
Date
Date
Yellow Fever:
Meningitis:
Rabies:
Hepatitis B
Jap B enchepalitis
Date
Date
Date
Date:
Date:
W;Westgate Medical Practice\Protocols and Guidelines\Vaccines and Travel Info\Travel Clinic Questionnaire
FOR OFFICE USE ONLY:
Nurse Signature:
Date:
Appointment Date:
Recommended Vaccinations for Travel
For All Travellers
Higher Risk Travellers
Highest Risk Travellers
Required Vaccinations (Note: charges apply to Non NHS)
NHS Vaccines
Non NHS Vaccines
Malarial Prophylaxis Recommended:
Comments:
I agree with above schedule and authorise administration by suitably trained practice
nurse.
GP Signature
Print Name
Date:
*This is a route of prescription for NHS vaccines. Once completed to go to seen by GP
pigeon hole for checking and signing then to travel tray at reception*
W;Westgate Medical Practice\Protocols and Guidelines\Vaccines and Travel Info\Travel Clinic Questionnaire
Westgate Travel Health Service
We currently offer a travel health service and aim to provide travellers with advice for safe
travel which may or may not include travel vaccinations.

When should you complete a travel questionnaire?
When you book your trip is when you should complete the questionnaire and book an appointment
for the Travel Clinic. This should be a minimum of four weeks prior to travelling to allow
adequate time to assess all requirements for travelling including vaccinations and malaria tablets
if required.

Who will I see at the Travel Clinic?
We have specially trained nurses who will assess and advise you.

What happens with my questionnaire once completed and handed in to the surgery?
The travel nurse receives the questionnaire and can then begin the assessment process.
Depending on where you are travelling and how complex your trip is dictates what advice you will
need and also what vaccinations may be required. Your notes are checked to see which
immunisations you have had which is then cross checked with the up to date recommendations
from the Travel and International Health Team of Health Protection Scotland (HPS).

Will there be any charges for this service?
Some vaccinations are available on the NHS:
Tetanus
Diphtheria
Polio
Typhoid
Hepatitis A
Non NHS available vaccinations can be provided as a private service and will incur charges for
prescribing, cost of vaccine (paid by yourself at the chemist dispensing) and then the
administration of the vaccines.
Private prescription:
Administration:
£10 per item
£30 per course
(Capped at £100 if requiring several
courses for one trip)
You will then have to pay the chemist the cost of the vaccine or the anti malaria tablets for
which prices may vary e.g.:
Hepatitis B vaccine private script
£12.99 per injection (not including VAT/chemist profit)
Course requires 3 injections
Administration of vaccine course
Total cost
£10.00
£38.97
£30.00
£78.93
Note: private prescriptions will take a minimum of 2 working days to be processed.
W;Westgate Medical Practice\Protocols and Guidelines\Vaccines and Travel Info\Travel Clinic Questionnaire

What if I need Yellow Fever Vaccination?
We do not provide this vaccine. To do so you need to be a registered centre. The following are
the registered centres in Dundee:
Grove Health Centre
Downfield Surgery
Princes Street Surgery
Superdrug Wellgate Centre

- 01382 778881
- 01382 812111
- 01382 461090
- 0854 0260830
When do I have to pay?
An invoice will be generated by the travel nurse detailing the charges to be paid to the practice
which will then be attached to any private prescriptions for vaccines/anti malaria tablets. You
will be asked to pay when you collect the prescriptions and before completion of any vaccine
courses. The cost of the vaccine itself is paid to the dispensing pharmacy.

I have a current or past illness, can I still have vaccinations?
Immunity is the ability of the human body to protect itself against infectious diseases. Vaccines
produce their protective effect by inducing active immunity. Some illness and medications can
effect immunity which in turn has implications when considering vaccinations. The travel nurse
will discuss this with you if appropriate when you attend the clinic. Vaccines require time to be
fully effective and this is why adequate time before travelling for them to be administers is
needed.

Last minute deals?
We are aware there are last minute deals however if there is less than 4 weeks before your trip
we will not be able to provide you with the full service. The travel nurse would assess this and
discuss the options with you. Alternatively there are private Travel Clinics run by both
Superdrug and Boots in the town centre but you will be charged for all vaccines including NHS
available.
W;Westgate Medical Practice\Protocols and Guidelines\Vaccines and Travel Info\Travel Clinic Questionnaire