TILEHURST SURGERY - PRE-TRAVEL FORM / TRAVEL RISK ASSESSMENT FORM
We run a full clinic offering both NHS free vaccination and chargeable private vaccinations. Please check the price list
at reception to see which vaccinations are chargeable.
BEFORE FILLING OUT THIS FORM PLEASE ENSURE YOU KNOW WHAT VACCINATIONS ARE REQUIRED IN
THE COUNTRY(S) YOU ARE TRAVELLING TO. FULL DETAILS CAN BE FOUND ON www.fitfortravel.nhs.uk.
If you are unable to access the internet please speak to reception when handing in this form.
Please read the travel health advice leaflet included before handing in this form.
Please complete this form and return to reception at least 8 weeks before you travel; we will contact you to
discuss your vaccinations. If you hand this form in at less then 8 weeks before you travel we cannot
guarantee we will be able to accommodate your request. For private vaccinations you can attend one of the
alternative travel clinics listed below:
Grovelands Travel Clinic (MASTA): 0118 9523623
Superdrug Chemist (Broad Street): 0844 3260393
Boots Chemist (The Oracle): 0118 9587529
NAME:
MALE / FEMALE
DATE OF BIRTH:
ADDRESS:
EASIEST CONTACT TELEPHONE NUMBER:
Please make sure you are available on this number during the day
Or EMAIL Address:
(We will contact you with your appointment time and date)
DATE OF DEPARTURE:
RETURN DATE OR OVERALL LENGTH OF TRIP:
ITINERARY AND PURPOSE OF VISIT:
Country to be visited and
Length of stay
areas/cities visiting.
1
2
3
Away from medical help at
destination? If so, how remote?
Please circle the descriptions that best describe your trip:
1. Type of Trip
Business
2. Holiday Type
Package
3. Accommodation
Hotel
Relatives/family home
Other
4. Travelling
Alone
With family/friend
In a group
5. Staying in area which is
Urban
Rural
Altitude
6. Planned activities
Safari
Adventure
Other
Pleasure
Camping
Selforganised
Other
Cruise Ship
Backpacking / Trekking
PERSONAL MEDICAL HISTORY:
Do you have any recent or past medical history of note? This includes diabetes, arthritis, heart or lung conditions and
thymus disorder?
LIST OF ANY CURRENT MEDICATIONS:
DO YOU HAVE ANY ALLERGIES, IE. EGGS,
ANTIBIOTICS, NUTS?
Have you ever had a serious reaction to a vaccine given to you 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 or depression?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only – are you pregnant, planning a pregnancy or breastfeeding?
Have you taken out travel insurance?
If you have a medical condition, have you informed the insurance company about this?
Please give any further information that may be relevant, including future travel plans in the next 12 months:
VACCINATIONS REQUIRED
What vaccinations do you require for where you are travelling? Please go to www.fitfortravel.nhs.uk before filling out
this form to find out what is recommended for the country(s) you are travelling to.
NHS Vaccinations (free)
□ Tetanus
□ Polio
□ Diphtheria
□ Typhoid
□ Hepatitis A
Private Vaccinations (paid)
□ Hepatitis B £40single,£120course
□ Rabies £55 single, £165 course
□ Yellow Fever £58
□ Meningitis ACWY £70
□ Japanese B Encephalitis £89
□ Tick Borne Encephalitis £65
□ Other
Malaria Tablets. £10 charge per prescription
If you require Malaria tablets please indicate which tablets you require and the number of tablets required.
□ Malarone (Atovaquone). No. of
□ Doxycycline. No. of tablets:
□ Mefloquine No. if tablets:
tablets:
Malaria Tablets available direct from chemist, no prescription required.
□ Chloroquine (purchase from
□ Proguanil (purchase from chemist)
chemist)
VACCINATION HISTORY
Have you ever had any of the following vaccinations/malaria tablets, and if so, when (please tick)?
□ Tetanus
□ Polio
□ Diphtheria
□ Typhoid
□ Hepatitis A
□ Hepatitis B
□ Rabies
□ Yellow Fever
□ Influenza
□ Meningitis ACWY
□ Japanese B Encephalitis
□ Tick Borne Encephalitis
□ Other
□ Malaria Tablets. Have you ever taken Malaria tablets?
Yes/ No (please circle)
Please sign to confirm you have received and read the travel health advice information leaflet included.
Signed: ________________________________
Date of handing in this form: _________
Please hand this form into reception. We will contact you with an appointment date and advise you of any possible chargeable
vaccinations at the time of booking.
Please bring sufficient payment to your appointment for any private vaccinations.
You may be required to have an additional travel appointment at a later date to complete your course of vaccinations.
If you have any queries please speak to Lisa Walker 0118 9439443 or Nurse Michelle on 0118 9427528