MITCHELDEAN SURGERY
TRAVEL ASSESSMENT FORM
Please complete this side only as fully as possible
Personal Details
Full Name:
Contact Telephone No:
Date of Birth:
Gender:
Your Itinerary and Purpose of Visit: (please indicate exact location or region)
Departure Date:
Return Date (or trip length):
Country(ies) to be visited
1.
2.
(and length of stay)
3.
4.
Additional Travel Plans
Away from medical help at
destination? If yes, how remote?
Please tick below as appropriate to best describe your trip:
 Business
 Pleasure
1.
Type of Trip
 Package
 Self-Organised
2.
Holiday Type
 Camping
 Cruise Ship
 Hotel
 Relatives’ Home
3.
Accommodation
 Alone
 With Family/Friend
4.
Travelling
 Urban
 Rural
5.
Staying in area
 Safari
 Adventure
6.
Planned Activities







Other
Back-Packing
Trekking
Other
In a Group
Altitude
Other
Personal Medical History (please use a separate sheet if necessary)
1.
Do you have any recent or past medical history of note (including
diabetes, heart or lung conditions
2.
List any current or repeat medications (or bring list with you)
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Do you have any allergies? (eg, eggs, antibiotics, nuts)
Have you ever had a serious reaction to a vaccine before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history of mental illness, including depression or
anxiety?
Do you have any kidney or liver problems?
Have you recently undergone radiotherapy, chemotherapy or steroid
treatment?
Women only: are you pregnant, planning a pregnancy or breastfeeding?
Have you taken our travel insurance? If yes, and you have a medical
condition, have you informed your Insurance Company about this?
Please add any further information which may be relevant (eg, YES answers
 Yes





Yes
Yes
Yes
Yes
Yes
 No





No
No
No
No
No
 Yes
 Yes
 No
 No
 Yes
 Yes
 No
 No
above)
Vaccination History
Have you ever had any of the following vaccinations/malaria tablets. If yes, please insert date.
Diphtheria
Influenza
Rabies
Tick Borne
Hepatitis A
Meningitis
Tetanus
Typhoid
Hepatitis B
Polio
Other
Other
Malaria Tablets
Jap B Enceph
Yellow Fever
MITCHELDEAN SURGERY
For Surgery Use Only:
Patient Full Name:
 Yes
 No OPAS PIN:
Travel Risk Assessment Performed:
Travel Vaccines Recommended for this Trip:
Disease Protection
Yes
No
Further Information
BCG/Mantoux Test
Cholera
Hepatitis A
Hepatitis B
Japanese B Encephalitis
Measles, Mumps, Rubella
Meningitis ACWY
Rabies
Seasonal Influenza
Tetanus, Diphtheria, Polio
Tick Borne Encephalitis
Typhoid
Yellow Fever
Travel Advice and Leaflets given as per Travel Protocol
Food, Water & Personal
Insect Bite Prevention
Insurance
Websites






Travellers’ Diarrhoea
Animal Bites
Air Travel
Travel Record Supplied






Hepatitis B & HIV
Accidents
Sun & Heat Protection






Malaria Prevention Advice & Malaria Chemoprophylaxis
Chloroquine & Proguanil
Chloroquine
Doxycycline



Antaquone & Proguanil (Malarone)
Mefloquine (Larium)
Malaria Advice Leaflet given
Further Information
Practitioner Name:
Date:
Declaration
I have no reason to think that I might be pregnant. I have received the 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 the charges
as outlined in the Travel Health Advice Leaflet which I have received.
Patient Signature:
Patient Full Name:
Date:


