travel risk assessment form

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ABOYNE MEDICAL PRACTICE
TRAVEL RISK ASSESSMENT FORM
Please complete the 1st page of this form prior to your travel advice appointment and return to Reception
Personal details
Date of birth:
Name:
Male [ ]
Female [ ]
Easiest contact telephone number
Dates of trip
Date of Departure:
Return Date:
Itinerary and purpose of visit
Countries to be visited Include
ANY stopovers
Length of
stay
Away from medical help at destination, if so,
how remote?
Please Circle as appropriate
Will you be staying under Primitive conditions, e.g. Camping
YES/NO
Are you visiting Friends or Relatives YES/NO
Does your journey include
COASTAL AREAS
INLAND AREAS
YES/NO
YES/NO
Do you plan any Safaris, jungle exploration or travel in difficult terrain YES/NO
Personal medical history
Do you have any recent or past medical history of note? (Including diabetes, heart or lung conditions,
thymus disorder)
List any current or repeat medications
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Is anyone in your household Immunosuppressed?
Have you had any other vaccinations in past 3 weeks
Women only: Are you pregnant or planning pregnancy or breast feeding?
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
Page 1 of 2
TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
(to be completed by Practice Nurse)
Disease protection
Last Date
Tick if
How
booster many
req’d
req’d
Fees
Hepatitis A
Typhoid
Tetanus
Diphtheria
Polio
Meningitis ACWY
Hepatitis B
Yellow Fever
Rabies
Cholera
Tick Borne Encephalitis
Japanese B Encephalitis
Other
Private prescriptions
Total cost
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
Malaria Prophylaxis Not Required
Advised to buy Malaria Tablets at Pharmacy
Requires appointment with GP
Travel and Malaria Advice given and reading material provided as per travel protocol
FIRST APPOINTMENT MADE FOR:
Signed by:
Position:
Date:
Patient Consent
I have received and understand the advice given to me concerning
Travel vaccination requirement
General Preventative measures
For myself
my child
And consent to the administration of the vaccinations identified above.
Signature ………………………..………………………………………………………..
Date
………………………………………………………………………………………
Page 2 of 2
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