Author: EMIS_2000
Last saved by: GP Tech
Company: NHS

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TRAVEL VACCINATIONS QUESTIONNAIRE
for HOLIDAY OR BUSINESS TRAVEL

The first sheet of this handout is for your information.  Please detach and keep for your reference.  Page 139 should be completed and returned to reception for processing, as soon as possible, prior to your intended travel plans, ideally at least 8 weeks before departure, so we can advise and arrange a programme for any required immunisations.  This is important as some vaccines do not confer adequate protection until up to 14 days after administration and others up to a year, particularly if you intend to 
travel for more than 3 months and/or to remote areas. 
A separate form is required for each family member traveling.
If you are currently pregnant or are planning a pregnancy, it is important that you tell the nurse for the 
safety of your baby.
Allow at least one week for the processing of this form – it is your responsibility to contact the 
surgery to make an appointment for you to commence your immunisations.
Children under 16 must have a parent present or come with a letter of parental consent to vaccinate.
A CHARGE MAY BE MADE FOR SOME VACCINATIONS ADMINISTERED (see page 138)
Any anti-malaria drugs not available for purchase at your pharmacy counter will be issued on
private prescription only for which we make an administration charge of £13:50,
the cost of the medication is payable to your pharmacy.
ALL CHARGES TO THE PRACTICE ARE PAYABLE IN ADVANCE OF VACCINATION

The vaccinations recommended by your nurse or doctor are based on the travel advice available at the time of your request.  Many countries have vaccines “sometimes recommended” which can cause variations in the recommended schedule.  If the information you supply on your completed form is incomplete or incorrect our recommendations may not be accurate.  Please remember vaccinations may not provide 100% cover if your immune response is poor.  The preventative advice offered should always be followed.

HEALTH ADVICE ON FOOD AND DRINK ABROAD

Diseases such as Typhoid, Hepatitis A and Cholera, as well as traveller’s diarrhoea, can be caught from contaminated food.

Often simple precautions can reduce these risks:
•	always wash your hands after going to the toilet and before handling food
•	if you are unsure about the safety of drinking water, either boil it, sterilise it with disinfectant tablets or buy sealed bottled water.
•	avoid ice cream and ice cubes unless you are sure the water used comes from a safe source.
•	avoid unpasteurised  milk
•	avoid raw vegetables, salads, fruit etc which may have been washed in contaminated water
•	avoid  raw shellfish such as oysters, in some countries fish and shellfish can be suspect, particular care must be taken
•	avoid food which has been re-heated or kept warm for long periods
•	try to keep to food which has been freshly cooked and is still hot.
continued over the page…

MALARIA PREVENTION

Malaria is a serious and potentially fatal disease which is spread by the bite of infected mosquitoes.  It is a widespread problem in most parts of Africa, Asia, Central and South America.  Prevention is based upon treatment with anti-malarial tablets combined with a measure to avoid mosquito bites, but may not be 100% effective.  A large proportion of malarial cases are potentially avoidable, and are a result of a failure to take anti-malarial tablets or poor compliance with the recommended course of treatment.
Any illness with a fever, either during or up to one year after travel to a malarial risk area, should be suspected as possible malaria and prompt medical attention sought.  Please read the following advice if you intend visiting a country where malaria is a problem.

Anti-malarial tablets (if recommended) 

Proguanil (Paludrine) (buy over the counter) 200mgs daily, plus Chloroquine 300mgs base weekly.
Proguanil (buy over the counter) 200mgs daily. Commence course 1 week prior to travel, during stay and continue 4 weeks on return.  (Supply of 5 weeks and number of weeks abroad).
Chloroquine (buy over the counter) 300mgs base weekly. Commence course 1 week prior to travel, during stay and continue 4 weeks on return.  (Supply of 5 weeks and number of weeks abroad).
Mefloquine, (private prescription only - £13:50 charge) one 250mgs tablet weekly. Commence course 3 weeks prior to travel, during stay and continue 4 weeks on return.    Not to be used in pregnancy, avoid pregnancy for 3 months after use. Mefloquine is contra-indicated in patients with a history of psychiatric disorders (including depression) or convulsions. (Prescription for 7 weeks and the number of weeks abroad.) Patient to be given Mefloquine advice sheet with prescription.
Doxycycline (private prescription only - £13:50 charge) one 100mg tablet daily. Commence course 2‑7 days prior to travel, during stay and 4 weeks on return.
Malarone, (private prescription only - £13:50 charge) one tablet daily. Commence course 2 days prior to travel, during stay and 7 days on return.
Anti-mosquito protection only (buy over the counter)

Mosquito bite avoidance.
Anti-malarial tablets alone cannot be considered 100% effective against malaria and it is, therefore, important to reduce the risk of mosquito bites.  Preventative measures include:
•	Use of insect repellants, particularly those containing 50% Deet (Diethyltoluamide).  These are best purchased in the UK prior to travel.
•	Repellants can be obtained in cream, pump action sprays, aerosol, gel, stick and moist wipes.  Popular brand names are Jungle Formula and Autan.  Effective cover may last only 2 to 4 hours and, therefore, need regular re-application.
•	Keep your arms and legs covered after sunset and apply repellant to exposed parts of the skin – especially ankles and wrists.
•	Light clothing may not afford adequate protection against mosquito bites
•	Use a ‘knock down’ spray in the bedroom
•	Use a mosquito net, preferably one impregnated with an insecticide around the bed at night
•	Use an anti-mosquito plug or burn a mosquito coil – electronic buzzers are ineffective

Patient’s Name: ………………………………………     	 	Patient’s GP: 
Patient’s Date of Birth: ……………………………….			     Dr………………………
Vaccines (provided by NHS) | Course of treatment | Period of cover

DIPTHERIA -booster  only or full course of 5 free if not had as a child (dip/tet/polio triple only available) (provided by NHS)

1^st vaccination given
2^nd – 28 days later
3^rd – 28 days later
4^th – 10 years later
5^th – 10 years later

10 years

TETANUS -  booster  only or full course of 5 free if not had as a child (dip/tet/polio triple only available) (provided by NHS)

1^st vaccination given
2^nd – 28 days later
3^rd – 28 days later
4^th – 10 years later
5^th– 10 years later

Full course of 5 gives cover for life

POLIO - booster  only or full course of 5 free if not had as a child (dip/tet/polio triple only available) (provided by NHS)

1^st vaccination given
2^nd – 28 days later      
3^rd – 28 days later
4^th – 10 years later
5^th – 10 years later

10 years

TYPHOID - one only needed (provided by NHS) | One only needed | 3 years

HEPATITIS A - course of two required (provided by NHS)

1^st vaccination given
2^nd – 6 to 12months later

1^st  = 1 year
2^nd = 10 yrs child
         25 yrs adult

ONLY THE ABOVE travel vaccinations may be supplied on the NHS free of charge
BELOW are travel vaccinations that should not be provided by the NHS free of charge, which will incur a private administration charge of £41:25 per course of vaccines, in addition to vaccine costs, payable in advance. Please enquire at reception for the current prices.
Vaccines (non-NHS) | Date of payment received | Course of treatment | Period of cover

HEPATITIS B - £-subject to change, costed at time of giving full course of 3 (non-NHS)

1^st vaccination given
2^nd dose – 1 month later
3^rd dose – 5 months later

Full course only

JAPANESE ENCEPHALITIS - £-subject to change, costed at time of giving full course of 3 – to be completed at least 14 days before travel by GP PRIVATE prescription per patient only (non-NHS)

1^st vaccination given
2^nd dose – 7 days later
3^rd dose – 7 or 21 days later

3years

RABIES - £-subject to change, costed at time of giving full course of 3 by GP PRIVATE prescription per patient only (non-NHS)

1^st vaccination given
2^nd dose – 7 days later
3^rd dose – 21 days later

If still at risk:
1yr booster:
then 5 yr booster

MENINGITIS ACWY  - £-subject to change, costed at time of giving to include the international certificate needed (non-NHS) | | One only needed | 3 years

CHOLERA - £-subject to change, costed at time of giving
only for living/working in poor conditions  (non-NHS)

One only needed

To be advised at time of giving

YELLOW FEVER –we cannot currently offer at this practice, patient must arrange to have elsewhere (non-NHS) | | One only needed at least 14 days before  travel | 10 years

NURSES NOTES
Live vaccines: give more than one live vaccine at the same time, in a different site, or three weeks apart
Japanese Encephalitis: severe reactions of angioneurotic oedema and dyspnoea can occur within minutes or up to two weeks after vaccine is given.  Therefore, the patient should wait in the surgery for 30 minutes after each dose, and the course should be completed 14 days before travel.

CONTRA-INDICATIONS / PRECAUTIONS CHECKLIST
1) allergy to vaccines		2) febrile illness	3) pregnancy		4) breast feeding
5) high dose steroids		6) diarrhoea / vomiting (oral polio)		7) HIV positive
8) immunosuppression therapy including radiation / chemotherapy (live vaccine)
9) immunosuppressed person in the household (live vaccine)

PLEASE COMPLETE AND RETURN		Date Received by the surgery ……………………
TO THE SURGERY FOR PROCESSING	Name of Patient’s GP ……………………………

Patient Name ……………………………………………………………………………………………...
Patient Date of Birth ……………………………………………………………………………………...
Patient Address …………………………………………………………………………………………
……………………………………………………………………………………………………………..
Patient Contact Phone Number …………………………………………………………………………..
1)  Reason for travel? (delete as appropriate) 	Business / Visiting family or friends / Holiday / Cruise
2)  What countries do you intend to visit, including brief stopovers? …………………………………...
…………………………………………………………………………………………………………….
3)  What type of accommodation? (delete as appropriate)	
Hotel / holiday resort / friends or relatives (rural) / backpacking / organized tour
4)  Departure date ………………………………………………………………………………………...
5)  Length of stay …………………………………………………………………………………………
6)  Does your journey include travel to rural or remote areas?  If YES please specify in detail …………
……………………………………………………………………………………………………………..
7) Who are you travelling with? (delete as appropriate) 	
Family / friends / partner / alone
8) How often do you travel abroad? ………………………………………………………………………
9) Specify any known allergies? ………………………………………………………………………….
10) Are you taking any steroid medication? ……………………………………………………………...
11) Are you planning a pregnancy / currently pregnant / breast feeding? (delete as appropriate) 	
12) Have you ever had any travel vaccinations at any other surgery or clinic?  If YES give details
	a) had…………………date……………..	e) had…………………date……………..
	b) had…………………date……………..	f) had…………………date……………..
	c) had…………………date……………..	g) had…………………date……………..
	d) had…………………date……………..	h) had…………………date……………..
* * * * * * *
PLEASE BRING WITH YOU ANY TRAVEL VACCINATION RECORDS YOU HAVE
* * * * * * *
REMEMBER IF YOU ARE TAKING MEDICATION, MAKE SURE YOU HAVE AN ADEQUATE SUPPLY
* * * * * * *

APPROVED BY THE QUALITY MANAGEMENT TEAM					    Issue Date: 01.07.2011
ISSUE 06