..CHEADLE MEDICAL CENTRE - PRE-TRAVEL FORM / TRAVEL RISK ASSESSMENT FORM..
We offer our patients a popular travel service run by our practice nurses. Please note that certain travel services are not
covered by the NHS so CHARGES WILL APPLY. Our current fees are available at Reception.
PLEASE NOTE: PLEASE CONTACT THE PRACTICE AT LEAST 12 WEEKS BEFORE YOUR TRIP TO ENSURE YOU
CAN BE SEEN AND FULLY IMMUNISED BEFORE YOU TRAVEL. YOU MUST FULLY COMPLETE THIS FORM AND
RETURN IT TO THE PRACTICE BEFORE WE CAN MAKE YOUR TRAVEL CLINIC APPOINTMENT, PLEASE HAND THE
FORM IN AT RECEPTION OR EMAIL IT TO admin.cheadlemedical@nhs.net AND ONE OF OUR STAFF WILL CONTACT
YOU TO ARRANGE AN APPOINTMENT.
From 2nd February 2015 Cheadle Medical Practice will no longer be a Yellow Fever Centre. We will therefore be unable to
provide Yellow Fever vaccinations.
Once your form has been handed in to the practice you will be contacted within 2 weeks. Please do not ring us
within that time, as the information will not be available.
If you are unable to give sufficient notice, we regret we will not be able to accommodate your request. You can contact any of
the clinics listed below:
Alternative Travel Clinics:
MASTA, Boots Mersey Way, Stockport
Total Travel, High Lane Medical Centre
Nomad Travel, Bridge Street, Manchester
Surrey Lodge Group Practice, Manchester
Tel: 0161 480 5424
Tel: 07736 794 813
Tel: 0161 832 2134
Tel: 0161 224 2471
www.masta-travel-health.com
www.totaltravelclinic.co.uk
PLEASE FULLY COMPLETE THIS FORM FOR EACH PERSON TRAVELLING AND RETURN IT TO THE PRACTICE
PERSONAL DETAILS
Name
Date of Birth
Male [ ]
Address
Age (at date of departure)
Daytime Telephone Number (Essential)
Female: [ ]
Email address
Postcode
DATES OF TRIP
Date of departure
Return date or
Overall length of
trip
DETAILS OF TRIP
Please list each country AND precise location(s) to be
visited
1
Length of stay
Further details
Eg. Remote/Rural, High Altitude etc
2
3
4
5
Please tick the descriptions that best describe your trip:
1. Type of Trip
Business [ ]
2. Holiday Type
Package [ ]
Hostel [ ]
3. Travelling
Alone [ ]
4. Location
Urban [ ]
5. Planned
activities
Are you planning any special activities? (eg safari, extreme sports, scuba etc) No [ ]
Please specify
Holiday [ ]
Visiting Family/Friends [ ]
Other [ ]
Hotel [ ]
Apartment/Villa [ ]
Relatives/family home [ ]
Camping [ ]
Cruise [ ]
Backpacking [ ]
Other [ ]
With family/friend [ ]
Rural [ ]
In a group [ ]
Altitude [ ]
Yes [ ]
PERSONAL MEDICAL HISTORY
Please give details of any medical history or medications (including over the counter) that may not be on your medical
records at the practice
FURTHER DETAILS
Do you have any allergies
(e.g. eggs, nuts, latex, antibiotics, medication)
Have you ever had a serious reaction to a
vaccine that you have received previously?
Does having an injection make you feel faint?
N
Y
If Yes, please give further details
Do you or any close family members have
epilepsy?
Do you have any history of mental illness or
depression?
Have you recently undergone radiotherapy,
chemotherapy or steroid treatment?
Women only – are you pregnant, planning a
pregnancy or breastfeeding?
Do you have appropriate travel insurance?
Yes [ ]
No [ ]
If you have been declined travel insurance or are paying a higher premium because of your medical history or the activities
you are undertaking, please give details.
Please give any further information that may be relevant:
VACCINATION HISTORY
If you have had any vaccinations outside the practice, please give details below or attach details
Type of Vaccine (eg Typhoid, Rabies)
Date
Place/Clinic where vaccine received
Have you ever taken Malaria tablets before? Yes [ ]
No [ ]
If yes, please specify the name and whether you had any side effects
Unsure [ ]
I confirm the information I have provided is accurate to my knowledge. I am happy to be contacted by the practice by phone,
email or post.
Signed: ________________________________
Date completed: _________________________
FOR OFFICE USE ONLY
Date form received
Admin initials
Form passed to Nurse [ ]
Nurse Comments
Appt
Date
Time
Patient given appt details [ ]
Nurse
To be completed during travel clinic appointment
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 and agree to comply with the advice given.
Signed: ________________________________
Date: _________________________