Travel risk assessment form

To be retuned at least 2 working days prior to appointment with
nurse.

Please complete this form prior to your travel appointment and return to reception.
Personal Details

Name:
_______________________________________________________________________________________________
Date of birth:
_______________________________________________________________________________________________ Contact telephone number: Email: GP name and address (if not registered at this surgery):
Dates of trip
Departure:

Itinerary and purpose of visit

Country to be visited
_____________________________________________________________________________ 1. _________________________________________________________________________________________________ 2. _________________________________________________________________________________________________ 3.
Please circle the descriptions that best describe your trip

1. Type of trip:


Personal medical history (please supply printout from own GP)

Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder
_________________________________________________________________________________________________
List any current or repeat medications
_________________________________________________________________________________________________
Do you have any allergies, for example to eggs, antibiotics, nuts, etc.?
_________________________________________________________________________________________________
Have you ever had a serious reaction to a vaccine given to you before?
________________________________________________________________________________________________
Do you or any close family members have epilepsy?
_________________________________________________________________________________________________
Do you have any history of mental illness, including depression or anxiety?
_________________________________________________________________________________________________
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
________________________________________________________________________________________________
Women only: Are you pregnant or planning pregnancy or breast feeding?
________________________________________________________________________________________________
Please give any further information that may be relevant, including any future travel plans:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________



Vaccination history

Have you ever had any of the following vaccinations/medication previously for travel? If so, when approximately?
Vaccination
Hepatitis A _________________________________________________________________________________________________ Hepatitis A Booster _________________________________________________________________________________________________ Hepatitis B: _________________________________________________________________________________________________ Japanese Encephalitis _________________________________________________________________________________________________ Malaria tablets _________________________________________________________________________________________________ Meningitis _________________________________________________________________________________________________ Rabies ________________________________________________________________________________________________ Typhoid _________________________________________________________________________________________________ Yellow Fever _________________________________________________________________________________________________ Yellow Fever Booster _________________________________________________________________________________________________ Childhood vaccinations, e.g. Tetanus _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
FOR OFFICIAL USE

Patient name:
Travel risk assessment performed: yes/no
Travel vaccines recommended for this trip:
Disease protection Yes/No/Further Information

Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Other
Travel advice and leaflets given as per travel protocol
Malaria prevention advice and malaria chemoprophylaxis Food, water and personal hygiene advice/ Travellers’ diarrhoea/ Hepatitis B, C and HIV Insect bite prevention/ animal bites/ accidents/ Insurance/ Air travel/ Sun and heat protection/ Hajj travel/ Travel record supplied Websites Other
Chloroquine and proguanil/ Atovaquone & proguanil (Malarone)/ Chloroquine/ Mefloquine/
Doxycycline/ Malaria advice leaflet given
Further information

Nurses Signature: ………………………………………………………………………………………………………….
_____________________________________________________________________________
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 have
been advised that I will be charged a fee for these vaccinations – see annex for charges. I have
been made aware that some of these vaccines may be available free from my own GP, however I
have chosen to be treated privately. I consent to the vaccines being given.
Signed:……………………………………………………………………………………Date:…………………………………………
.

Source: http://www.whmp.co.uk/Downloads/Travel%20Risk%20Assessment%20Form.pdf