Travel Risk Assessment Form

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Travel Risk Assessment Form
Personal details
Name……………………………………………………………………….
Tel no……………………………….
Date of Birth………………………………………………………….........
Male/Female……………………….
Dates of travel ……………………………………………………………………………………………………..
Disclaimer : Please note that advice given is based on the details you give on this form.
It is your responsibility to give all relevant information.
Country to be visited
Length of stay
Away from medical help at destination?
If so, how remote?
Please circle the descriptions that best describe your trip
Business
Pleasure
Other
1. Type of trip
Package
Self organised
Backpacking
2. Holiday type
Camping
Cruise ship
Trekking
3. Accommodation
Hotel
Relatives/Family home
Other
4. Travelling
Alone
With Family/Friend
In a group
Urban
Rural
Altitude
5. Staying in an area which is
6. Planned activities
Safari
Adventure
Other
Personal Medical History
Do you have any allergies for example to eggs, antibiotics, nuts?...........................................
Have you ever had a serious reaction to a vaccine given to you before?................................
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/immunocompromised?…………….
Have you taken out travel insurance? If you have a medical condition, have you informed the insurance
company about this?.............................................
Vaccinations received previously (if known)……………………………………………………………………………...
Please give any information that may be relevant including any future travel plans
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………
Women only: I have no reason to think I may be pregnant and am not planning a pregnancy or breast feeding.
All: The information given on this form is accurate and complete to the best of my knowledge.
Signed:
Date:
Travel Risk Assessment Form
Personal details
Name……………………………………………………………………….
Tel no……………………………….
Date of Birth………………………………………………………….........
Male/Female……………………….
Dates of travel ……………………………………………………………………………………………………..
Disclaimer : Please note that advice given is based on the details you give on this form.
It is your responsibility to give all relevant information.
Country to be visited
Length of stay
Away from medical help at destination?
If so, how remote?
Please circle the descriptions that best describe your trip
Business
Pleasure
Other
1. Type of trip
Package
Self organised
Backpacking
2. Holiday type
Camping
Cruise ship
Trekking
3. Accommodation
Hotel
Relatives/Family home
Other
4. Travelling
Alone
With Family/Friend
In a group
Urban
Rural
Altitude
5. Staying in an area which is
6. Planned activities
Safari
Adventure
Other
Personal Medical History
Do you have any allergies for example to eggs, antibiotics, nuts?...........................................
Have you ever had a serious reaction to a vaccine given to you before?................................
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/immunocompromised?…………….
Have you taken out travel insurance? If you have a medical condition, have you informed the insurance
company about this?.............................................
Vaccinations received previously (if known)……………………………………………………………………………...
Please give any information that may be relevant including any future travel plans
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………
Women only: I have no reason to think I may be pregnant and am not planning a pregnancy or breast feeding.
All: The information given on this form is accurate and complete to the best of my knowledge.
Signed:
Date:
Travel Vaccine Information Card
Patient Name
D.O.B.
Travel Risk Assessment performed
Yes (
)
No (
)
TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
Disease protection
Yes
No
Further information
Hepatitis A
Hepatitis B
Typhoid
Tetanus /Diphtheria/Polio
Meningitis ACWY
Cholera
Yellow Fever
Rabies
Japanese B Encephalitis
Other
GP consent given for administration of vaccine as indicated above
Signed…………………………………………..Dated…………………………………
GP name………………………………………

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