Wickham Market Medical Centre
Travel Risk Assessment form
Please complete and return to the surgery before your initial appointment.
Name:
Date Of Birth:
Male [ ]
Easiest Contact telephone Number:
Email Address:
Trip details:
Date Of Departure:
Return Date or Overall Length of Stay:
Itinerary and Purpose of Visit
(if multiple destination i.e. Cruise please provide full itinerary)
Country to be Visited
Length of Stay
Female [ ]
Away from Medical
help at Destination? If
so how remote?
1.
2.
3.
Please tick appropriate below to best describe your trip:
1. Type Of Trip
Business
Pleasure
Other
2. Holiday Type
Package
Self-organised
Backpacking
Camping
Cruise ship
Trekking
3. Accommodation
Hotel
Relatives/Family
Other
homes
4. Travelling
Alone
With
In a Group
Family/Friend
5. Area in which you
Urban
Rural
Altitude
are staying
6. Planned Activities
Safari
Adventure
Other
Personal Medical History
Do you have any recent or past medical history (including diabetes, heart or lung
conditions)?
List any Current or repeat medications?
Do you have any allergies (i.e. eggs, nuts, antibiotics)?
Have you ever had a serious reaction to a vaccine?
Does having an injection make you feel faint?
Do you or any close relatives suffer from epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only: Are you pregnant or planning pregnancy or breast feeding?
Have you taken out travel insurance and if you have a medical condition, informed the
insurance company about this?
Please write below any further information which may be relevant (e.g. History of any
vaccines different from surgery records or been administered elsewhere).
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 question. I consent
to the vaccines being given.
Signed___________________________________________ Date__________________
For Surgery use Only:
Patient Name:
Travel Risk assessment performed:
Date of Birth:
Yes [ ]
No [ ]
Travel Vaccines Recommended for the Trip
Disease Protection
Yes
No
Further Information
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
MMR
Other
Travel Advice and Leaflets Given as per Travel Protocol:
Food water & personal
Hygiene advice
Insect Bite prevention
Travellers’ Diarrhoea
Hepatitis B and HIV
Animal Bites
Accidents
Insurance
Air Travel
Sun & Heat protection
Websites
Travel Record Card supplied?
Other?
Malaria Prevention Advice & Malaria Chemoprophylaxis
Chloroquine & proguanil
Chloroquine
Doxycycline
Further Information
e.g. weight of child
Signed by:
Atovaquone & Proguanil (Malarone)
Mefloquine
Malaria advice leaflet given
Position:
Please ensure this form is scanned on to the patient’s record.
Date
Price List For Vaccines
Vaccine
Meningitis (Menveo)
Hepatitis B
Hepatitis B Booster
Rabies
Japanese Encephalitis – Adults
Only
Twinrix Adult x3 Injections
Initial Course
Twinrix Adult – Annual Booster
HIV Test
Cholera
Tetanus
Polio
Hep A (1st & 2nd doses)
Typhoid
Total Cost to patient
Total Cost
 If
Patient
requires
for
travelling.
For
Surgery
use
ONLY
(if this
requires
ordering)
For
Surgery
use
ONLY
(if this
requires
Ordering)
£58.00
£92.34
£30.78
£192.72
£210.40
£188.88
£62.96
£51.00
Free
Free
Free
Free
Free
£
Signed when ordered……………………………………………………….
Date ……………………………………………………..
For surgery use only
Please detach and attach to Vaccines on arrival.
Name of Patient……………………………………………………………………………….
Appointment date ……………………………………………………………………………