Appointment date/time
Barton Central Surgery
Travel Health Questionnaire
Please read the information provided and complete the attached form as fully as possible
before returning it to Barton Central Surgery, You will be contacted within approximately 1
week by the surgery to let you know if you need to book an appointment for vaccinations or
to attend for a travel clinic appointment. It is essential therefore that you include up to date
contact information and always inform the surgery of any changes to your details.
PLEASE ALLOW AS MUCH TIME AS POSSIBLE - some vaccines require a course
of injections and you may leave yourself unprotected if you do not allow
sufficient time.
Our travel nurse will undertake a travel health risk assessment based on the information
you provide – please fill the assessment form in as fully and accurately as possible - the
nurse is not aware of your travel plans unless you include the relevant information. If you do
not include enough information you may not benefit form the best advice and this could
leave you more vulnerable to travel associated health risks.
The travel health assessment includes travel destination/ intensity of risk in visit area/
season of travel/ Duration of travel/ purpose of travel/ accommodation / exposure to
mosquitos/ current NHS immunisation status. Travel health is about more than just vaccine
preventable risks.
The nurse will discuss with you any recommended and suggested travel vaccines, it is
advisable for you to research your destination in order to allow you to make informed
choices on which vaccinations to have. The decision whether or not to be vaccinated is for
you to make.
PLEASE NOTE: NOT ALL VACCINES ARE FREE ON THE NHS - for example
Hepatitis B/Cholera/Meningitis ACWY/Rabies/Japanese Encephalitis/Yellow
Fever and more.
The surgery uses NaTHNaC and Travax websites as well as the ‘Green book’ and the ‘yellow
book’ as the primary source of up-to-date travel health risk information.
Please find attached GSK Travel Well form for you to keep which offers advice on many
travel related issues, as well as a list of suggested websites. We strongly recommend that
you read the information provided and visit the websites listed before you attend for your
appointment, as they will assist your understanding of the health risks of your destination as
well as the vaccines recommended for your trip.
Personal Details
Name in Full
Date of Birth
Address
Age
Telephone
Male/Female
Details of trip
Date of departure
Overall length of trip
Date of return
Countries to be
visited
Region/area to be
visited
Length of stay
Away from medical help?
1.
2.
3.
4.
Please tick all that apply
Business
Pleasure
Other
Package holiday
Self-organised
Backpacking
Camping holiday
Cruise
Trekking
Accommodation types
Hotel
Relative/family home
Other
Rural
Jungle
Adventure
Other
With family/friend
In a group
Area description
Urban
Planned activities
Safari
Are you travelling…
Alone
Please note any other relevant information about your trip
Personal Medical History – please answer all questions with as much detail as possible
You have any recent or past medical history of note?
List any current medications you are taking
Do you have any allergies?
Have you ever had a serious reaction to a vaccine given to you?
Do you or any family members have epilepsy?
Do you have a history of mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you had any disease of the thymus or myasthenia gravis?
Are you HIV positive?
Are you pregnant?
Planning pregnancy?
Breastfeeding?
Vaccine History – have you had any of the following? (if yes, please give dates)
Tetanus
Polio
Diphtheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Pneumococcal
Jap B Enc
Tick Borne Enc
Malaria Tablets
Other (please state)
For Surgery Use Only
Travel risk assessment undertaken by (name):
Date:
Travel Vaccine recommendations (please also indicate if up-to-date
Disease protection recommended
YES
NO
Further Information
Hepatitis A
Typhoid
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Cholera
Hepatitis B
Malaria
Is there a risk of malaria?
Y/N
ABCD of malaria discussed?
Y/N
Chemoprophylaxis required?
Y/N
Chloroquine
Proguanil
Doxycycline
Atovaquone/Proguanil (Malerone)
Mefloquine
Prescription requested?
Y/N
Doses required
General travel advice
Prevention of
Mosquito bite
accidents
avoidance
Personal safety and
Sun and heat advice
security
Food and water borne
Insurance advice
risks
Travellers’ diarrhoea
Rabies specific advice
advice
Sexual health & blood
Travel advice leaflet
borne virus risk
given
Source of advice used for travel information: NaTHNac
TRAVAX
Other