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Appendix 2: travel risk assessment form

Travel Health Risk Assessment Form

Please complete page 1 & 2 prior to your travel appointment and bring all 3 pages to the Travel Nurse.
Personal details
Name:
_____________________________________________________________________________________________________
Date of Birth:
_____________________________________________________________________________________________________ Easiest contact telephone number: _____________________________________________________________________________________________________ E.mail:
_____________________________________________________________________________________________________
GP name and address if not enrolled at this medical practice:
_____________________________________________________________________________________________________
Date of Departure……………………………………………
Overall length of trip……………………………….

Itinerary and purpose of visit

Country to be visited
_____________________________________________________________________________________________________ 1.
_____________________________________________________________________________________________________
2.
_____________________________________________________________________________________________________
3.
_____________________________________________________________________________________________________
4.
_____________________________________________________________________________________________________
5.
_____________________________________________________________________________________________________
6.
_____________________________________________________________________________________________________
Please circle the descriptions that best describe your trip
1.
_____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. Other………………………………. _____________________________________________________________________________________________________ 4. _____________________________________________________________________________________________________ 5. _____________________________________________________________________________________________________ 6. _____________________________________________________________________________________________________
Personal medical history
Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorder.
_____________________________________________________________________________________________________
List any current or repeat medications.
_____________________________________________________________________________________________________
Do you have any allergies, for example to eggs, antibiotics, nuts?

Patient Name:

Date of Birth:

Have you ever had a serious reaction to a vaccine given to you before?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Does having an injection make you feel faint?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Do you or any close family members have epilepsy?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Do you have any history of mental illness, including depression or anxiety?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Women only: Are you pregnant or planning pregnancy or breast feeding?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you taken out travel insurance? If you have a medical condition, have you informed the insurance company about this?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Please give any further information that may be relevant, including any future travel plans.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Vaccination history

Have you ever had any of the following vaccinations/malaria tablets, and if so, when?
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Other _____________________________________________________________________________________________________ Malaria tablets _____________________________________________________________________________________________________ For discussion when risk assessment is performed within your appointment: I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given. Signed:
For official use


Patient name: Authorising Doctor………………………………………………………

Travel risk assessment performed Yes [ ] No [ ] Authorisation for Nurse to administer vaccination.
Signed……………………………………………………………………. _____________________________________________________________________________________________________
Travel vaccines recommended for this trip
Disease protection Recommended Further information

Hepatitis A
_____________________________________________________________________________________________________
Hepatitis B
_____________________________________________________________________________________________________
Typhoid
_____________________________________________________________________________________________________
Cholera
_____________________________________________________________________________________________________
Tetanus/Diptheria
_____________________________________________________________________________________________________
MMR
_____________________________________________________________________________________________________
Polio
_____________________________________________________________________________________________________
Meningitis ACWY
_____________________________________________________________________________________________________
Yellow Fever
_____________________________________________________________________________________________________
Rabies
_____________________________________________________________________________________________________
Japanese B Encephalitis
_____________________________________________________________________________________________________
Other Travel Record card supplied
_____________________________________________________________________________________________________
Travel advice and/or leaflets given as per travel protocol

Food, water and personal hygiene advice Travellers diarrhoea Hepatitis B, C and HIV _____________________________________________________________________________________________________ Insect bite prevention Rabies Accidents Insurance Air travel _____________________________________________________________________________________________________ Sun and heat protection Hajj travel Yellow Fever Blood borne virus _____________________________________________________________________________________________________ Global Traveller Checklist Malaria Altitude sickness Cruise ship travel _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Malaria prevention advice and malaria chemoprophylaxis

Atovaquone + proguanil (Malarone) Chloroquine Mefloquine Doxycycline
_____________________________________________________________________________________________________
Further information
e.g. weight of child
Signed by:

Source: http://www.moorhousemedical.co.nz/resources/file/Travel%20Health%20Risk%20Assessment%20Form.pdf

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Animal research highlights a therapeutic potential of cannabinoids for the treatment of depression Regina A. Mangieri Department of Pharmacology, The University of Texas at Austin, Austin, TX 78712, USA Abstract Long known for their mood altering effects, cannabinoids are currently under investigation for their therapeutic potential in the treatment of depression. Findings from multi

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