V8.0 NHS BORDERS TRAVEL HEALTH PATIENT QUESTIONNAIRE

Return form via e-mail to vaccination.bookinghub@borders.scot.nhs.uk
Return form via post to NHS Borders Vaccination Hub, 7 Tweedside Park, Tweedbank, Galashiels, TD1 3TE
Forms may also be handed in an envelope to the health board reception team in an NHS Borders health centre.

PERSONAL DETAILS
Full name	Enter name.	Sex	Male ☐ Female ☐
Date of birth	Enter date.	Address	Enter address.
Mobile telephone	Enter mobile number.
Home telephone	Enter home number.
GP practice	Enter GP practice.	Emergency contact name & number	Enter emergency contact.
E-mail address	Enter e-mail address.

YOUR TRIP
Total length of your trip	Enter length of trip.
Destination(s) countries and specific places (areas, cities) including stopovers	Arrival Date	Departure date
1. Enter destination.	Enter date.	Enter date.
2. Enter destination.	Enter date.	Enter date.
3. Enter destination.	Enter date.	Enter date.
4. Enter destination.	Enter date.	Enter date.
5. Enter destination.	Enter date.	Enter date.
TYPES(S) OF TRAVEL (Tick all that apply)	YES	ACTIVITIES (Tick all that apply)	YES
Holiday Provide details.	☐	Visiting friends/relatives	☐
Cruise Provide details.	☐	Sports/adventure	☐
Business	☐	High risk, inc drug use, tattoos, unprotected sex	☐
Backpacking Provide details.	☐	Altitude	☐
Pilgrimage Provide details.	☐	Working with animals	☐
Remote away from medical access Provide details.	☐	Healthcare work	☐
Hotel	☐	Medical tourism	☐
Camping/hostels Provide details.	☐	School Trip (Detail school below)	☐
Safari Provide details including location.	☐ Guided safari YES ☐ NO ☐	Volunteer work	☐ Working with children/school YES☐ NO☐
Any additional information about your trip? Additional information.
MEDICAL HISTORY	NO	YES	DETAILS
Have you ever had a severe allergic reaction or anaphylaxis in the past?	☐	☐	Enter details.
Are you taking any medication including prescribed, purchased, contraception, or having any regular treatment?	☐	☐	Enter details.
Women only	Are you Pregnant	☐	☐	Enter details.
Are you breastfeeding	☐	☐	Enter details.
Planning to be pregnant soon or whilst away	☐	☐	Enter details.
Do you suffer from any diagnosed long term conditions we should be aware of including immunosuppression’s?
Enter details i.e. mental health, chemotherapy, radiotherapy, diabetes etc.

VACCINATION HISTORY
You MUST PROVIDE details and dates of all previous vaccinations, including childhood immunisations which may be provided on a separate sheet. You may need to contact your GP practice to request a copy of your vaccination history.
BCG/TB	Enter details.
Cholera	Enter details.
Diptheria/ Tetanus/ Polio	Enter details.
Hepatitis A	Enter details.
Hepatitis B	Enter details.
Japanese Encephalitis	Enter details.
Meningitis ACWY	Enter details.
MMR	Enter details.
Rabies	Enter details.
Tick Borne Encephalitis	Enter details.
Typhoid	Enter details.
Yellow Fever	Enter details.
Dengue Fever	Enter details.
Pneumococcal	Enter details.
Influenza	Enter details.
COVID-19	Enter details.
Any additional information	Enter details.