GIGGS HILL SURGERY - TRAVEL RISK ASSESSMENT FORM
Please complete this form and return it to the surgery at least 2 days prior to your appointment which should be at least 6 weeks before you
travel. Please familiarise yourself with your destination’s disease risks and precautions on www.fitfortravel.nhs.uk before your appointment.


Some vaccinations are not available on the NHS and there will be a charge for these
Some less common vaccines may need to be ordered and this may delay treatment.
PERSONAL DETAILS:
Name
Date of Birth:
Phone NO.
Significant Medical History/Allergies:
Pregnant? Yes/No
Planning Pregnancy? Yes/No
Breastfeeding? Yes/No
TRAVEL ITINERARY
Date of departure:
Destination(s):
City/rural
Duration of stay:
Accommodation: Hotel / Hostel / Family home / Camping etc
Reason for trip: Holiday / Business / Visiting friends & family / Backpacking / Aid work / Medical
Higher risk activities?
Insurance - any pre-existing medical conditions notified to company?
Dates of Previous travel vaccinations - Please bring a copy of this record in with you.
Previous serious reaction to a vaccine or malaria chemoprophylaxis?
DECLARATION:
I have consulted www.fitfortravel.nhs.uk and have an understanding of the risks that I may be subjected to and, consequently, the necessary
precautions including those involving:

Food and water contamination

Blood and body fluid exposure

Animal bites

Mosquito bites.
Signature:_________________________________________________
Date: _____________
(Please use the travel consultation as an opportunity to discuss the information on www.fitfortravel.nhs.uk)
OFFICIAL USE ONLY (Information from Travax website)
Patient consent to vaccine/malaria chemoprophylaxis?
Recommended
Y
N
Vaccine/dose/route – PSD valid
Schedule
for 1.5 years from signing to cover
booster doses.
Epaxal 0.5ml 1ml IMI
Havrix 0.5 1ml
IMI
Hepatyrix 1ml
IMI
Viatim 0.5mls
IM
Engerix B 20mcg/ml 1ml IMI
Engerix B paediatric 0.5ml IM
Twinrix 20mcg/ml 1ml IMI
Twinrix paediatric 0.5ml
Ambirix 20mcg/ml 1ml IMI
Typhim VI 0.5ml IMI
Vivotif live oral tablet x 3(>6yrs)
Typherix 0.5mls IMI
Hepatyrix 1ml IMI
Viatim 0.5mls IMI
Dukoral Orally
Stat & boost in 6/12m
Stat & boost in 6/12m
Stat
Stat
0,7,21d&12m/ 0,1,2&12m/ 0,1&6m
0, 1, 2,12m/ 0,1&6m
0,1,6m/0,7,12d&12m
0,1,6m
0 & 6-12m
Revaxis 0.5mg/1ml IMI
Stat (full course if indicated)
Nimenrix 0.5ml IMI
Stat
Yellow fever
Stamaril 0.5ml s/cut
Stat
Rabies
Rabies vaccine BP 0.5ml IMI
Verorab 0.5ml IMI
Rabipur 0.5ml IMI
0,7,21/28d
Jap b encephalitis
Ixiaro 0.5ml IMI
Day 0, 28
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus,
diphtheria polio
Meningitis ACWY
Y
N
Notes:
Stat
Day 0,3,5.
Stat
Stat
Day 0, 7-36
Other
Malaria
Chemoprophylaxis
Outbreaks / also
discussed
Insect bite avoidance plus Deet
50% twice daily
As per Travax site:
*N= not indicated, * U= vaccine has already been given/ is up-to-date, *A= for certain areas/risk categories
Assessors Name:
W. GODDIN
S. BROCK
Signature:
Date:
Prescribers Name:
DOCTOR
Signature:
Date: