St Stephen’s House Surgery
Yellow Fever Risk Assessment Form
Name
Address
Date of Departure
Dob
Age
Total length of trip
Countries to be visited in order of
itinerary
1
2
3
4
Holiday
Business trip
safari
Telephone
Exact location
Length of stay/hours in
airport transit
Type of travel and purpose of trip – tick all that apply
Staying in hotel
Backpacking
Cruise ship trip
Camping/hostels
Other (details)
Personal medical history
Yes
No
Details
Are you fit and well today
Any allergies including eggs
Severe reaction to a vaccinebefore
Recent chemotherapy/radiotherapy/ organ
transplant
Any history of compromised immunity
Any history of thymus dysfunction including
thymoma, thymectomy
HIV/Aids
Are you currently taking any medication If yes list below
1
2
3
4
5
Yes
No
6
7
8
9
10
Have you had a yellow fever vaccine anytime in the past
YES
No
St Stephen’s House Surgery
Yellow Fever Risk Assessment Form (page 2)
Have you had a live vaccine within the previous 4 weeks, e.g. MMR, BCG,
Varicella vaccines?
Yes
No
Women Only
Are you pregnant?
Yes
No
Are you breast feeding?
Yes
No
Are you planning pregnancy while away?
Yes
No
Are you currently taking any medication If yes list below
Yes
No
1
2
3
4
5
1
2
3
4
5
The section below is to be completed by St Stephen’s House Surgery Nurses only
Vaccine advice provided to patient, please tick below as appropriate
Potential side effects of Yellow Fever vaccine discussed
Yes
Patient information leaflet (pil) from packaging or www.medicines.org.uk/emc given
Yes
Advice leaflet from Nathnac given to patient on Yellow Fever and insect bite avoidance
Yes
Has patient been advised on malaria?
Yes
No
Is there a Yellow fever requirement for this trip?
Yes
No
Has the patient been issued with an exemption certificate where there is
no risk of yellow fever to the patient but a certificate requirement
Yes
No
International health regulations
Yellow Fever - Patient Specific Direction – To be signed by GP prior to administration:
Assessor’s name:
Prescribers name:
Signature:
Signature:
Date:
Date: