ROSEMOUNT MEDICAL GROUP
TRAVEL RISK ASSESSMENT FORM
Please READ and complete this form fully and legibly
Personal Details
First Name :
Surname :
Date of Birth :
Male / Female
Home Telephone Number :
Mobil Number :
Date of Departure of Holiday :
Return Date or length of Trip :
Do any of the following apply to you ?
I am pregnant / or plan to become pregnant within 3 months of travel
Yes / No
I am taking steroids or have had a joint injection for pain within the last 3 months
Yes / No
I am suffering from a disease of the immune system
Yes / No
I am allergic to drugs or food (e.g. eggs) Please specify :
Have you even taken medicine for :
Epilepsy
Depression
Skin complaints
Yes / No
Yes / No
Yes / No
Please list any medical condition requiring regular supervision or medication :
Please list any regular medication you are taking :
DO YOU HAVE TRAVEL INSURANCE?
Yes / No
If you have a medical condition have you informed them of this?
Yes / No
Travel Health Questionnaire / Information Sheet
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Rosemount Medical Group
Itinerary and Purpose of Visit
Country to be visited :
Exact site of stay (town, city, area) :
Is medical help available at this destination ?
Yes / No
Please tick as appropriate below to best describe your trip :
Type of Trip
Holiday Type
Accommodation
Travelling
Staying in area which is
Planned Activities
Business
Package
Camping
Hotel
Alone
Urban
Safari
Pleasure
Self Organised
Cruise Ship
Other
Backpacking
Trekking
Other
Other
Altitude
Other
Family/Friends Home
With family / friend
Rural
Adventure
Vaccination history (please bring any evidence of previous vaccines to appointment)
Have you even had any of the following vaccinations / malaria tablets and if so when ?
Tetanus
Typhoid
Meningitis
Rabies
Malaria Tablets
Polio
Hepatitis A
Yellow Fever
Jap B Enceph
Measles
Diphtheria
Hepatitis B
Influenza
Tick Borne
PLEASE READ AND SIGN
I have no reason to think that I might be pregnant. The information I have given is correct to the best
of my knowledge. I consent to any recommended vaccines being given to m e after discussion with
the health profession.
Signed ____________________________________________ Date _________________________
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
NURSE USE ONLY :
Vaccinations required for trip ____________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Referral to Specialist Clinic indicated _____________________________________________________________________________
___________________________________________________________________________________________________________
Script done – Date _________________________________
Appointment given – Date ____________________________
Additional notes ______________________________________________________________________________________________
___________________________________________________________________________________________________________
Signed ____________________________________________ Date _________________________
Travel Health Questionnaire / Information Sheet
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Rosemount Medical Group
TRAVEL CLINIC
IMPORTANT INFORMATION
The Practice Travel Clinic provides information and advice to travellers in order to protect
their health and prevent illness.
Before deciding on the information and advice required a risk assessment must be carried
out. Information regarding your travel plans, your past and current health and immunisation
status is an essential requirement in this process. Please complete the travel health
questionnaire as fully as possible.
It will not normally be possible for travellers to receive immunisations at the initial travel clinic
appointment – this appointment is directed towards the collection of adequate information and
the risk assessment for the traveller.
The Practice Travel Clinic is not appropriate for certain categories of traveller :
1. Where, at short notice, travel is for business / work. Employers have a duty to provide
advice for their employees either through their medical advisor or a private travel clinic.
2. Complicated travel itineraries – specialist travel advice is often necessary for complex
travel and this is out with the scope of our travel clinic – such travellers will be directed
to specialist travel clinics.
3. If travelling with less than 6 weeks notice, we may be unable to provide travel health
advice due to time constraints on available appointment times.
4. Children under school age should have their travel health care provided at a specialist
travel health clinic.
Most immunisations are available on NHS prescription but others which may be
recommended, particularly for travel abroad to ‘exotic’ destinations, are only available
privately.
Travel Health Questionnaire / Information Sheet
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Rosemount Medical Group