DeMontfort Medical Centre – Patient Travel Questionnaire
The purpose of this form is to assess what vaccinations if any are required before you travel. The form
should be completed at least one month prior to travel. If you require vaccinations you will be informed
what these are by the nurse. Please note that there is a charge for a number of travel vaccinations. You
will be informed of this at your appointment.
Dates of Trip
Departure Date:
Return Date:
Length of Trip:
Personal Details
Name:
Contact Telephone Number:
Email:
Date of Birth:
Male [ ]
Female [ ]
Itinerary and Purpose of Visit:
Countries to be Visited:
Length of Stay:
Is medical help available at
destination?
1.
2.
3.
4.
Vaccination History
Have you ever had any of the following vaccinations/malaria tablets? If so, give date beside the
vaccination.
Hepatitis A
Meningitis
Hepatitis B
Typhoid
Yellow Fever
Jab B Enceph
Dip/Tet/Polio
Rabies
Malaria Tablets
Other
Please Tick as Appropriate Below to Best Describe your Trip
1. Type of Trip
2. Holiday Type
3. Accommodation
4. Travelling
5. Staying in area
which is:
6. Planned Activities
Business
Package
Camping
Hotel
Alone
Urban
Pleasure
Self Organised
Cruise Ship
Family Home
With family/friends
Rural
Other
Backpacking
Trekking
Other
In a group
Altitude
Safari
Adventure
Other
Personal Medical History
Do you have any recent or past medical history of any note? (including diabetes, heart or lung conditions)
List any current repeat medications:
Do you have any allergies? For example to eggs, antibiotics, nut or latex
Have you ever had a serious reaction to a vaccine before?
Personal Medical History Continued
Does having a vaccine make you feel faint?
Do you or any of your close family members have Epilepsy?
Do you have any history of mental illness including depression?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only: Are you pregnant, breast feeding or planning pregnancy?
Have you taken out travel insurance and if you have a medical condition, informed the insurance
company about this?
Please write here any further information which may be relevant.
Patient Consent
For discussion when risk assessment performed during your appointment:
I have no reason to think that I might be pregnant. I have received information on the risks and benefits of
vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being
given.
Signed ............................................................ Date ..................................................
For Official Use – to be completed by members of staff only.
Patient Name:
Travel Risk Assessment Performed: Yes [ ] No [ ]
Travel advice recommended for this trip
Disease Protection
Yes
No
Consider
Patient Declined Vacc
Further Info
Hepatitis A
Typhoid
Diptheria/tetanus/Polio
Hepatitis B
Cholera
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Other
Malaria Prevention advice and Malaria chemoprophylaxis
Atovaquone + Proguanil
Chloroquine =/Proguanil
Malaria advice leaflet given
Doxycycline
Mefloquine
Other
Travel advice and leaflets given as per travel protocol
Insect bite prevention
Accidents
Travel record card given
Food, water & personal hygiene
Sun and heat protection
Websites – fit for travel
Animal bites
advice
Blood & bodily fluid infection
risks
Other
Authorisation for Patient Specific Direction
Assessors name: ....................................... Signature: ................................................ Date: ..........................
Prescribers name: ..................................... Signature: ................................................. Date: .........................
For Reception Staff – patient appointment
Travel advice only
Travel advice and immunisations