Travel risk assessment form

SMALLBROOK SURGERY
Travel risk assessment form
Please complete this form at least 2 weeks prior to your travel
appointment and return it to reception.
Personal details:
Name: ……………………………………………………………………………… Date of Birth: ………………………………………… Male [ ] Female [ ] Easiest contact telephone number: …………………………………………….
Email: ……………………………………………………………………………….
Dates of trip: ……………………………………………………………………….
Date of departure: ………………………………………………………………… Return date or overal length of trip: …………………………………………….
Itinerary and purpose of visit: …………………………………………………… Please circle the descriptions that best describe your trip: 1. Type of trip – Business/Pleasure/Other (please detail) 2. Holiday type – Package/Self-organised/Backpacking/Camping/ Cruise ship/Trekking 3. Accommodation – Hotel/Relatives/Family Home/Other (please detail) 4. Travel ing – Alone/With family/Friend/Group 5. Staying in an area which is – Urban/Rural/High altitude 6. Planned activities – Safari/Adventure/Other (please detail) Personal Medical History:
Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus disorders.
…………………………………………………………………………………….
…………………………………………………………………………………….
…………………………………………………………………………………….
…………………………………………………………………………………….
…………………………………………………………………………………….
…………………………………………………………………………………….
Do you have any al ergies, for example to eggs, antibiotics, nuts? Yes [ ] No [ ] If yes, which? …………………………………………………….
Have you every had a serious reaction to a vaccine given to you before? Yes [ ] No [ ] If yes, which? …………………………………………………….
Does having an injection make you feel faint? Yes [ ] No [ ] Do you or any close family members have epilepsy Yes [ ] No [ ] If yes, who? …………………………………………………………………………………….
Do you have any history of mental il ness, including depression or anxiety? Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Yes [ ] No [ ] If yes, which? …………………………………………………………………………………….
Women only: Are you pregnant or planning pregnancy or breast feeding? Yes [ ] No [ ] If yes, which? …………………………………………………….
Have you taken out travel insurance? Yes [ ] No [ ] If you have a medical condition, have you informed the insurance company about this? Yes [ ] No [ ] Please give any further information that may be relevant, including any future travel plans.
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
Vaccination History:
Have you ever had any of the fol owing vaccinations/malaria tablets, and if so, when? Vaccination
TetanusPolioDiptheriaTyphoidHepatitis AHepatitis BMeningitisYel ow FeverInfluenzaRabiesJapanese B EncephalitisTick borne EncephalitisOther ChloroquineProguanilMefloquineMalaroneDoxycycline A ful risk assessment wil be performed within your first appointment with the travel nurse.
I have no reason to think that I would be pregnant.
Travel risk assessment performed: Yes [ ] No [ ] Travel vaccinations recommended for this trip: Hepatitis AHepatitis BTyphoidCholeraTetanusDiptheriaPolioMeningitis ACWYYel ow FeverRabiesJapanese B EncephalitisOther Malaria chemoprophylaxis required: Yes [ ] No [ ] ChloroquineProguanilMefloquineMalaroneDoxycycline Information in patient’s records: Yes [ ] No [ ]

Source: http://www.smallbrooksurgery.co.uk/assets/51/Travel_Risk_Assessment_Form.pdf