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