TRAVEL RISK ASSESSMENT FORM
Please complete the first 2 pages of this document, and read the enclosed information on schedules and
costs of vaccinations.
Please bring the completed assessment form with you to your appointment. Please note we are unable
to conduct the consultation without this document.
Surname:
Forename:
Date of Birth:
Male/Female (please circle)
Contact No: Mobile:
Home:
Email:
Travel Itinerary:
Destinations(inc stopovers)
Are there healthcare standards at your destination
YES/NO
Date of Departure:
Length of stay:
(Please circle as appropriate)
Purpose of trip
Business
Accommodation
Hotel
Planned activities
Safari
Pleasure
Hostel
Relatives
Adventure
Other
Other
Other
Mode of transport:
Medical History:
Do you have any recent or past medical history of note? This includes diabetes, heart of lung conditions,
thymus disorder etc.?
YES/NO
Do you have any Allergies?
YES/NO
Are you pregnant, breast feeding or planning pregnancy?
YES/NO
Are you currently taking medications, including over the counter medications:
Have you ever had a serious reaction to a vaccine ?
YES/NO
YES/NO
Does having an injection make you feel faint?
YES/NO
Do you or any of any family member have epilepsy?
YES/NO
Do you have any history or mental illness (in depression or anxiety)?
YES/NO
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
YES/NO
Please give any further information that may be relevant, including any future travel plans.
Vaccination History
Have you had any of the following vaccinations/malaria tablets, and if so when (please tick and date as
appropriate)?
Tetanus
Typhoid
Meningitis
Rabies
Other
Malaria tablets
Polio
Hepatitis A
Yellow Fever
Jap B encephalitis
Diptheria
Hepatitis B
Influenza
Tick borne encephalitis
I confirm that I have read the information on schedules and costs of vaccines, and understand that it is
my responsibility to attend in sufficient time to complete any vaccination courses advised.
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 consent to the vaccines
being given.
Signed:
Date:
Four Elms Medical Centre
Travel vaccination costs and schedules for adults
Please be aware that certain vaccines need to be ordered, and this can take 2-3
days. Please ensure you have attended the surgery with sufficient time to order
and complete any courses of vaccination. It generally takes around a month
following completion of a course of vaccine for full immunity to develop within
the body. Therefore it is advisable to attend at least 1 month prior to your travel
date if you are going on a short (2 week) package holiday or similar, and around 3
months in advance if you are going for a longer period of time/ backpacking. It is
your responsibility to ensure you have booked in with sufficient time for your
needs.
NB depending on age, children have different requirements for travel vaccination, and
this needs to be discussed on an individual basis with the nurse conducting your travel
health consultation.
Tetanus, Diphtheria and polio: free. You need to have had 5 doses of each in your
lifetime to have adequate immunity, they form part of the routine childhood
immunisation programme. IF you are in any doubt, please discuss this with the nurse at
your appointment.
Hepatitis A: free. 1 dose needs to be given at least a month before your travel date. A
booster dose at 6-12 months will give loner term immunity.
Typhoid: free. 1 dose needs to be given at least a month before your travel date. It
lasts for 3 years.
Hepatitis B: £30 each dose. This is a course of 3 doses, given at 0,1 and 6 months,
and the course should be completed at least a month before your travel date.
Accelerated schedules can be given at 0,1 and 2 months, with a booster dose at 12
months; or 0,7 and 21 days, with a booster dose at 12 months. Again, the course of 3
should be completed at least a month before your travel date. If immunity needs to be
checked following vaccination, this should be done 6-8 weeks following the full course.
Yellow fever: £55. A certificate will be given, which is valid from 10 days post
vaccination. Yellow fever consists of 1 dose, valid for 10 years, and should be given at
least 10 days prior to arriving in risk area.
Rabies: £45 each dose, course of 3=£135. This is a course of 3 doses initially, given at
0,7 and 28 days- the third dose can be given at 21 days if there is insufficient time
before travel. The course should be completed at least a month before your travel date.
Meningitis ACWY: ranges from £45 to £65, depending on the type chosen (please
discuss with your nurse). A certificate will be given. This is a single dose, and should be
given at least a month before your travel date. The certificate is valid from 10 days
following vaccination.
Tick- borne encephalitis: price on application. This is a course of 3 doses, given at 0,
1-3 and 5-12 months. For rapid protection, the 2nd dose can be given 2 weeks after the
first dose, and this provides around 90% immunity. The course should be completed at
least a month before your travel date.
Malaria tablets: Four Elms charge £10 for a private prescription if this is needed for
malaria tablets, the cost of the actual tablets depends on your destination and which
regime you have chosen. Some regimes are started 2 days before you arrive in the risk
area, but some need to be started up to a week before you go.
NB prices correct at time of printing.
The Four Elms Medical Centres
FOR OFFICIAL USE / TO BE PUT FOR SCANNING ONCE SIGNED BY GP
(PATIENT SPECIFIC DIRECTION)
Patient Name:
1.
Patient Number:
Travel risk assessment performed
Y/N
2.
Travel Vaccines recommended for this trip
Disease protection
Yes
No
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus/Diptheria/
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B
encephalitis
Other
Further Information
3.
Travel advice and leaflets given as per travel protocol
Food / water /
Traveller’s
Hepatitis B, C,
Insect bite
hygiene / advice
diarrhoea
HIV
avoidance
Accidents
Air Travel
Sun/heat
protection
Travel record
Websites
other
supplied
Animal bites
Hajj Travel
4.
Malaria prevention advice and malaria chemoprohylaxis
Chloroquine and proguanil
Atovaquone +proguanil (malarone)
Chloroquine
Mefloquine (checklist)
Doxycline
Malaria advice leaflet
Good mosquito bite precautions only
5.
Further information:
e.g. Weight of child
Signed (patient):
Date:
Signed (Doctor):
Date: