GROVE PARK TERRACE SURGERY TRAVEL VACCINATION RISK ASSESSMENT FORM
PERSONAL DETAILS
Name:
Male [ ]
Female [ ]
Contact numbers: mobile:
E-mail:
Date of birth:
other tel no:
ITINERY AND PURPOSE OF VISIT
Date of departure:
Purpose of visit:
return date /overall length of trip:
Countries to be visited
length of stay
if there is no medical help at your destination
please state how remote it is.
1.
2.
3.
Any future travel plans?
Please tick to indicate below, as appropriate, to best describe your trip:
TYPE OF TRIP
HOLIDAY
TYPE:
Business
Package
ACCOMMODATION:
TRAVELLING:
Hotel
TICK ALL
THAT APPLY:
ACTIVITIES:
urban
rural
coastal resort
safari
adventure
other
Alone
Pleasure
other
self-organised back-packing
or trekking
(please
indicate)
Villa
relatives/
family home
with family
in a group
or friend
camping
cruise
other
hostel
tent
other
other
altitude
other
PERSONAL MEDICAL HISTORY
Do you have any recent or past medical history of note? inc. diabetes, heart or lung conditions
List any current / repeat medications
List allergies eg. eggs, antibiotics, nuts, latex, wasp/bee stings
Have you ever had a serious reaction to a vaccine?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history of metal illness, depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment
Women: Are you pregnant, planning pregnancy or breastfeeding?
Have you taken out travel insurance and, if you have a medical condition, informed the insurance company about
this?
Any other relevant information:
VACCINATION HISTORY
Have you ever had any of the following vaccinations /malaria tablets? Please give dates.
Tetanus
Polio
Diphtheria
Typhoid
Hepatitis A
Hepatitis B
Yellow fever
influenza
rabies
Jap B Enceph
Tick borne
Meningitis
other
Malaria tablets
Please sign below when you attend your appointment:
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
N.B. Before you receive your travel vaccinations we recommend that you visit www.8weekstogo.co.uk and follow the links
FOR OFFICIAL USE:
Patient name:
Travel risk assessment performed
Yes[ ]
No [ ]
Travel vaccines recommended for this trip
Disease protection
yes
no
Patient declined vaccine
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow fever
Rabies
Japanese B
Encephalitis
Other
Travel advice and leaflets given as per travel protocol
Food, water and personal hygiene
Traveller’s diarrhoea
advice
Insect bite prevention
Insurance
Websites
Animal bites
Air travel
SMS vaccines reminder
set up
further information
Blood and bodily fluid
infection risks eg Hep B
Accidents
Sun and heat protection
Travel record card supplied
Other
Malaria prevention advice and malaria chemophrophylaxis
Chloroquine and proguanil
Atovaquone + proguanil
Chloroquine
Mefloquine
Doxycycline
Malaria advice leaflet given
Further information
eg. Age of child
Weight of child
Authorisation for Patient Specific Direction (PSD) Use
Assessor’s name……………………………Signature………………………………………….date………………..
Prescribor’s name ………………………….Signature………………………………………….date………………..