2016
ST JAMES’S TRAVEL RISK ASSESSEMENT FORM-patient to complete
PATIENT TO COMPLETE 4-5 WEEKS PRIOR TO TRAVEL
Please be aware that whilst we will try our best, it may not always be possible to
accommodate your travel needs if you have short notice travel plans and we have limited
appointments.
NAME:
DOB:
Email:
Telephone:
Date of departure:
Mobile:
Total length of trip:
Country to be visited:
1.
M/F
Exact location or region:
City/rural
Length of stay:
2.
3.
Type of travel and purpose of trip – please tick all that apply
holiday
hotel
backpacking
business
Expatriate
cruise
Safari
Adventure
Camping/hostels
Volunteer work
Pilgrimage
Healthcare work Medical tourism Visiting family
Diving
Travel insurance? Y/N
Do you plan to travel abroad again in the future?
Please supply details of your medical history
Y
N
Details
Are you fit and well today
Allergies – including food, latex, medication
Severe reaction to previous vaccination
Past operations, inc. removal of spleen and
thymus gland
Recent chemotherapy/radiotherapy/transplant
Immune system condition
Mental health inc. anxiety and depression
Pregnant or breast feeding
Current medication
Please supply any records of vaccinations/malarial tablets that you may have had previously.
2016
Travel risk assessment form – to be completed by health professional
Health Professional use only in conjunction with Travel Risk Assessment Form
Patient Name:
DOB:
Travel risk management performed by: name&date
Disease
protection
advised
BCG/Mantoux
Cholera
Yes
DT/IPV
Hep A
Hep B
Hep A&B
Hep A&typhoid
Jap B
Disease
protection
advised
Influenza
Meningitis
ACWY
MMR
Rabies
TBE
Typhoid
Yellow Fever
Other
Yes
Malaria
chemoprophylaxis
recommendation
Atovaquone/proguanil
Chloroquine only
Yes/
Discuss
Choloroquine&proguanil
Doxcycline
Mefloquine
Proguanil
Weight of child
Authorisation for a Patient Specific Direction (PSD)
Following the completion of a travel risk assessment, the below named vaccines may be
administered under this PSD to :
NAME:
DOB:
Vaccine name
Dose & schedule
Prescriber:
signature & date
To
discuss
St James’s surgery travel advice leaflet given: Y/N (all topics below in patient information
leaflet). Patient advised to read leaflet due to insufficient time to advise verbally during consult on
every topic.
Items ticked below indicate topics discussed specifically during the consultation:
Prevention of accident&insurance advice
Mosquito& insect bite prevention
Food and water borne risks
Malaria prevention advice
Sexual health&blood borne virus risk
Sun& heat advice
Rabies specific advice
Travellers’ diarrhoea advice