Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Where possible please submit travel forms at least 8 weeks before date of travel, otherwise we can not guarantee there will be time for an assessment to be completed or an appointment available.

Travel Risk Assessment

Travel Risk Assessment

If you are human, leave this field blank.

Section

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country to be visited, length of stay, and how remote you'll be from medical help:

Holiday type:

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

Type of trip:

Business

Pleasure

Other

Accommodation:

Hotel

Relatives / family home

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Other

List any recent or past medical history of note:

Including diabetes, heart or lung conditions

List any current or repeat medications:

List any allergies:

Have you ever had a serious reaction to a vaccine given to you before?

Yes

No

Don't Know

Does having an injection make you feel faint?

Yes

No

Don't Know

Do you or any close family members have epilepsy?

Yes

No

Don't Know

Do you have any history or mental illness including depression or anxiety?

Yes

No

Don't Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Don't Know

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Yes

No

Don't Know

Are you pregnant or planning pregnancy or breast feeding?

Please write below any further information which may be relevant:

Have you ever had any of the following vaccinations / malaria tablets?

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Influenza

Rabies

Jap B Enceph

Tick-borne Enceph (TBE):

Other / Malaria tablets

Please state which year you had the vaccination(s):

Tetanus: *

Polio: *

Hepatitis A: *

Hepatitis B: *

Meningitis: *

Influenza: *

Rabies: *

Jap B Enceph: *

Tick-borne Enceph (TBE): *

Diptheria: *

Typhoid: *

Other / Malaria tablets please list here: *

Signed: *

Date:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent - I understand that I will be contacted at least 4 weeks before I travel

For Official Use

Patient Name

Travel Risk Assessment Performed?

Yes

No

Nurse Signature:

Date:

Travel vaccines recommended for this trip

Disease protection

Yes/No

Patient declined vaccine

Vaccine name, dose & schedule for PSD

Hepatitis A

Hepatitis B

Typhoid

Cholera

Tetanus

Diphtheria

Polio

Meningitis ACWY

Rabies

Japanese B Encephalitis

Other

Authorisation for Patient Specific Direction (PSD) Use

Name

Signature

Date

Travel Advice and leaflets given as per travel protocol

Food, water and personal hygiene advice

Insect bite prevention

Insurance

Websites

Travel record card supplied

Travellers' diarrhoea

Animal bites

Air travel

Blood and bodily fluid infection risks e.g. Hepatitis B

Accidents

Sun and heat protection

SMS vacines reminder service set up

OtherOther

Malaria prevention advice and malaria chemoprophylaxis

Chloroquine and proguanil

Chloroquine

Doxycycline

Atovaquone + proguanil

Mefloquine

Malaria advice leaflet given

Further Information

(e.g. weight of child)