Travel Risk Assessment

Section

Can we contact you by email?

Yes

No

Can we contact you by text message?

Yes

No

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country to be visited, length of stay, and how remote you'll be from medical help:

Any future travel plans?

Type of trip:

Business

Pleasure

Other

Holiday type:

Accommodation:

Hotel

Relatives / family home

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Other

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)

List any current or repeat medications

Do you have any allergies for example to eggs, antibiotics, nuts or latex?

Have you ever had a serious reaction to a vaccine given to you before?

Yes

No

Don't Know

Does having an injection make you feel faint?

Yes

No

Don't Know

Do you or any close family members have epilepsy?

Yes

No

Don't Know

Do you have any history or mental illness including depression or anxiety?

Yes

No

Don't Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Don't Know

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Yes

No

Don't Know

Are you pregnant or planning pregnancy or breast feeding?

Please write below any further information which may be relevant:

Have you ever had any of the following vaccinations / malaria tablets?

Which year did you have the Tetanus vaccination? *

Which year did you have the Polio vaccination? *

Which year did you have the Hepatitis A vaccination? *

Which year did you have the Hepatitis B vaccination? *

Which year did you have the Meningitis vaccination? *

Which year did you have the Yellow Fever vaccination? *

Which year did you have the Influenza vaccination? *

Which year did you have the Rabies vaccination? *

Which year did you have the Jap B Enceph vaccination? *

Which year did you have the Tick Bourne vaccination? *

Which year did you have the Diptheria vaccination? *

Which year did you have the Typhoid vaccination? *

If 'Other / Malaria tablets' please list here: *

Which year did you have the other vaccination / malaria tablets? *

Signed: *

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

Date:

Please note that the details you give will be used to update your medical records.

For Official Use

Patient Name:

Travel risk assessment performed

Yes

No

Travel vaccines recommended for this trip

Hepatitus A

Yes

No

Patient declined vaccine

Further information

Hepatitus B

Yes

No

Patient declined vaccine

Further information

Typhoid

Yes

No

Patient declined vaccine

Further information

Cholera

Yes

No

Patient declined vaccine

Further information

Tetanus

Yes

No

Patient declined vaccine

Further information

Diphtheria

Yes

No

Patient declined vaccine

Further information

Polio

Yes

No

Patient declined vaccine

Further information

Meningitus ACWY

Yes

No

Patient declined vaccine

Further information

Yellow Fever

Yes

No

Patient declined vaccine

Further information

Rabies

Yes

No

Patient declined vaccine

Further information

Japanese B Encephalitis

Yes

No

Patient declined vaccine

Further information

Other .....................

Yes

No

Patient declined vaccine

Further information

Travel advice and leaflets given as per travel protocol

Food, water and personal hygiene advice

Travellers' diarrhoea

Blood and bodily fluid infection risks e.g. Hepatitus B

Insect bite prevention

Animal bites

Accidents

Insurance

Air Travel

Sun and heat protection

Websites

SMS vaccines reminder service set up

Travel record card supplied

Other

Malaria prevention advice and malaria chemoprophylaxis

Chloroquine and proguanil

Atovaquone + proguanil

Chloroquine

Mefloquine

Doxycyline

Malaria advice leaflet given

Further information

e.g. weight of child

Authorisation for Patient Specific Direction (PSD) Use

Assessor's Name:

Signature:

Date:

Prescriber's Name:

Signature:

Date:

*

I confirm that the information provided is accurate to the best of my knowledge.

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Section

For Official Use

Travel vaccines recommended for this trip

Travel advice and leaflets given as per travel protocol

Malaria prevention advice and malaria chemoprophylaxis

Further information

Authorisation for Patient Specific Direction (PSD) Use

Hay Fever