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Nhsgrampian.org

Dr Peter Kiehlmann
Dr Christine Paterson

Dr Ade Ogunnupe
Dr Damian McGrory

Working together, caring for your health
Assistants
Dr Rhona McKeown
Dr Julie Cooper

Danestone Medical Practice
Fairview Street, Danestone, Aberdeen AB22 8ZP Telephone: (01224) 822866 Fax: (01224) 849699 TRAVEL CLINIC QUESTIONNAIRE

NOTE: Complete 1 Form for EACH Traveller

Please complete this form and hand into reception no less than 6 weeks prior to
If immunisations required please make a 20 minute appointment with the Practice Nurse. *Note (If travelling within 6 weeks, please contact a Private clinic:
Capita Health Solutions: 01224 669001, Masta Travel Clinic: 01224 562747 ARE YOU STAYING IN HOTEL OR PRIVATE HOME?: ARE THERE ANY DETOURS OR STOPOVERS IN YOUR PLEASE TURN OVER
V:\INHOUSE\Masters\Travel Questionnaire Jan2011.doc TRAVEL CLINIC QUESTIONNAIRE (Continued)

Have You Been Immunised Previously Against:

Are you taking any regular medications? If YES, please list: …………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………. Are you taking ZYBAN? YES/NO Do you have any allergies? If YES, please list including any allergies to medicines or immunisations: ……………………. ……………………………………………………………………………………………………………………………….
I confirm the above answers to be correct to the best of my knowledge and request
immunisation as appropriate to my trip together with advice on anti-malarial drugs.

PATIENT’S SIGNATURE …………………………………….

DATE…………….
(Parents Signature if Patient under 16)

If you have internet access you can browse the following websites:

www.malariahotspots.co.uk

V:\INHOUSE\Masters\Travel Questionnaire Jan2011.doc

Source: http://www.nhsgrampian.org/files/Travel%20Questionnaire%20Jan2011.pdf

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