TRAVEL CLINIC CONSENT FORM
Date Taken
Taken By
Passed to Nurse
Passed Back to Reception
Patient EMIS Number
***FOR INTERNAL USE ONLY***
Malaria
Pharmacy Advice [ ] Script Req’d [ ]
Appointment
Single [ ] Double [ ] Not Req’d [ ]
Patient Informed ☐ (By__________ Date _____________)
Appt Date & Time
Nurse
FOR THE PATIENT TO COMPLETE
Personal Details
Name
Date of Birth
Contact No.
Male [ ] Female [ ]
Address
Dates of Trip
Date of Departure
Length of Trip
Details about Destination(s)
Country
Location
Length of Stay
1.
2.
3.
Do you plan to travel abroad again in the future? Yes [ ] No [ ]
Please tick as appropriate below to best describe your trip
1. Type of Trip
Business
Pleasure
Other
Package
Self-Organised
Backpacking
2. Holiday Type
Camping
Cruise Ship
Trekking
3. Accommodation
Hotel
Relatives/Family Home
Other
4. Travelling
Alone
With Family/Friend
In a Group
5. Area
Urban
Rural
Altitude
6. Activities
Safari
Adventure
Other
Personal Medical History
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
Are you on any current or repeat medications?
Do you have any allergies?
Have you had any previous reactions to any vaccines?
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?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only: Are you pregnant, planning a pregnancy or breastfeeding?
Please write any further information which may be relevant
Updated 150114 SH (shared/shared misc forms/forms/travel form)
Vaccination History
Have you ever had any of the following vaccinations/malaria tablets and if so when?
Tetanus
Polio
Diphtheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Other
Malaria Tablets
FOR THE NURSE TO COMPLETE
Patient Name
Travel Risk Assessment Performed Yes [ ] No [ ]
Travel Vaccinations Recommended for this Trip
Disease Protection
Yes
No
Patient Declined Vaccine
Vaccine Given
Recorded
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Other
Travel Advice Given as per Travel Protocol
Travax [ ] Nathnac [ ]
Food, Water & Personal Hygiene
Travellers’ Diarrhoea
Blood/Bodily Fluid Infection Risks
Insect Bite Prevention
Animal Bites
Accidents
Insurance
Air Travel
Sun & Heat Protection
Websites
Travel Record Card Given
Other
Malaria Prevention Advice and Malaria Chemoprophylaxis
Chloroquine and Proguanil
Atovaquone & Proguanil
Chloroquine
Mefloquine
Doxycycline
Malaria Advice Leaflet Given
Further Information
(Including weight if below 16yrs old)
PATIENT CONSENT
(To be completed at the time of the appointment)
I am well today. 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 questions. I consent to the
vaccines being given.
Signed: ______________________________________ Date: _______________________________
Updated 150114 SH (shared/shared misc forms/forms/travel form)