For office use only:
Reviewed by nurse: _____________________
Date of Admin appointment: ______________
AMPLEFORTH AND HOVINGHAM SURGERIES
Confidential Travel Risk Assessment and Travel Risk Management Form
To be completed by the traveller prior to appointment
Traveller:
Address:
DoB:
Home Tel:
Mobile Tel:
Email address:
Details of your trip
Date of departure:
Country to be visited
1.
Exact location or region
Total length of trip:
City/Rural
Length of stay
2.
3.
Have you taken out travel insurance for this trip? Y/N
Do you plan to travel abroad again in the future
Type of travel and purpose of trip – please tick all that apply





Holiday
Business trip
Expatriate
Volunteer work
Healthcare worker





Staying in hotel
Cruise ship trip
Safari
Pilgrimage
Medical tourism





Backpacking
Additional information
Camping/hostels
Adventure
Diving
Visiting friends/family
Please supply details of your personal medical history
Are you fit and well today
Any allergies including food, latex, medication
Severe reaction to a vaccine before
Tendency to faint with injections
Any surgical operations in the past, including e.g. your spleen or
thymus gland removed
Recent chemotherapy/radiotherapy/organ transplant
Anaemia
Bleeding/clotting disorders (including history of DVT)
Heart Disease (e.g. angina, high blood pressure)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal (stomach) complaints
Liver and or kidney problems
HIV/AIDS
Immune system condition
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Y
N
Y/N
Rheumatology (joint) conditions
Spleen problems
Any other conditions?
Women only
Are you pregnant
Are you breast feeding?
Are you planning pregnancy?
Are you currently taking any medication? (including prescribed and purchased)
<Current Repeat Issues(table)>
<Current Acute Issues(table)>
Please record information on any vaccines or malaria tablets taken in the past in the grid below.
Tetanus/polio/diphtheria
Typhoid
Cholera
Rabies
Yellow Fever
Malaria tablets
MMR
Hepatitis A
Hepatitis B
Japanese Encephalitis
BCG
Influenza
Pneumococcal
Meningitis
Tick Borne Encephalitis
Other
To help you the ones we have recorded on our system are:
<Vaccinations(table)>
Any additional information
Please note:
Some vaccines are available on the NHS as part of the National Immunisation Schedule, others are supplied privately
and there will be a cost. Please ask at Reception for details the prices are subject to change.
Patient signature:
Date:
Travel risk assessment form taken from the Royal College of Nursing Travel Health Nursing Advice.