MEDICAL STUDENT:
MEDICAL ELECTIVE TRAVEL ASSESSMENT APPOINTMENT FORM
Surname:
Mr/Ms/Mrs/Miss/Dr
First Name :
Date
Dateofofrequest:
birth:
Home address:
Department/College/Organisation:
Contact Telephone no.
Have you visited the Travel Clinic
previously?
E-mail:
YES / NO
Individual or Group travel? (If group, are
you the group leader?)
YES / NO
Destination/s (include all countries and main cities/towns/areas to be visited/ stop overs):
Date of departure:
Duration of trip:
Purpose of visit: include a brief description
of the type of accommodation and
activities to be performed
Placement medical information request
forms attached
Yes / No
Have you ever had, or do you now have any long-standing or temporary health condition(s), which could
affect your fitness to travel?
Examples would be a history of DVT, Heart or Respiratory disease, Diabetes, Pregnancy, recent surgery or
injury
YES / NO
Please complete the following vaccination history to date:
You may need to contact your GP surgery for this information:
Tetanus/Diphtheria
/Polio
Hepatitis A
Typhoid
Yellow Fever
Yellow Fever
Meningitis B
Rabies
Seasonal
vaccination
Meningitis ACWY
TicoVac
Jap Encephalitis
Other
Influenza
I certify that the travel arrangements for which I am requesting travel advice and vaccination has approval by my Head
of Department or my Departmental Central Administrator.
N.B. This travel relates solely to journey/s to be taken on official University of Oxford business.
Signed………………………………………………………… Date: …………………………………………...
The information collected on this form is processed in accordance with the principles of the Data Protection Act 1998.
All information you provide is held securely in confidence as part of your medical record by the Occupational Health
Service.
To be completed by OH only
Appointment required: Yes/No
Vaccinations required (please tick):
Td/IPV
Appointment with: Physician/Travel Nurse Specialist
Hepatitis A
Typhoid
Hepatitis B
Influenza
Yellow Fever
Rabies
Meningitis: B
or ACWY
Jap
Encephalitis
Tico Vac
MMR
Varicella
Cholera
Other
Advice and/or Other Medication required (please tick):
Malaria advice and
or medication
Bite prevention
advice given
Traveller’s
Diarrhoea
advice given
Other (e.g. health
issues identified
from risk
assessment)
Confirmation of :
Hepatitis blood test results
HIV blood test
results:
TB
Blood test results
Scar visible
Yes / No
OHA/OHP
Signature:
Date:
Hepatitis C blood test
results: