QUEEN EDITH MEDICAL PRACTICE
TRAVEL RISK ASSESSMENT FORM

Please complete this form prior to your appointment and return to reception at least one month before you travel. This form will be given to the nurse then we ask that the patient calls at least a week later to find out what is recommended (see leaflet for more information)

PLEASE NOTE:
 We will only administer those vaccinations available on the NHS. Should you require any additional non-NHS vaccinations (indicated with a * on the final page of this form), you will need to have these done at a Private Travel Clinic.

Full Name:	Date of Birth:                                        Male [  ]  Female [  ]	
Address:	Easiest tel contact no:	
		
Date of departure:	Return date or overall length of trip:	

Where are you going?

Country to be visited	Exact location or region	City or Rural?
Medical help at destination?	Length of stay	
1)				
2)				
3)				

Type of travel and purpose of trip
 
Please tick all that apply	
Pleasure 	Business	Volunteer work	Expatriate	
Healthcare worker	Pilgrimage	Package	Backpacking	
Camping/hostels	Diving	Cruise ship	Trekking	
Safari	Altitude	Staying with family/friends		
Additional Info				

TRAVEL RISK ASSESSMENT continued

Personal Medical History

Personal Medical History – do you have any recent or past medical history of note?  This includes diabetes, heart or lung conditions, thymus disorder, spleen removed. 	
	
Are you fit and well today?	
	
List any current or repeat medications	
	
Do you have any allergies? Including food, latex, medication.	
	
Have you ever had a serious reaction to a vaccine 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.	

	

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                                  [  ] 	Japanese B Enceph             [  ]	Tick Borne                            [  ]	
Other	
Malaria Tablets  Y/N   If yes, which ones?	

For discussion when risk assessment is performed within your appointment:

I have no reason to think that I might be pregnant.  I consent to the vaccines being given.

Signed:                                                                                                 Date	

FOR PRACTICE USE ONLY

Patient Name:                                                                                             D.O.B	

Travel vaccine recommended for this trip	
Yes	
No	
Further Information	

Hepatitis A				

Hepatitis B*				

Typhoid				

Cholera*				

Tetanus				

Diphtheria				

Polio				

Meningitis ACWY*				

Yellow Fever*				

Rabies*				

Japanese B Encephalitis*				

Other*				

				
*These vaccinations are not available on the NHS and therefore will NOT be administered at the practice. If required for the area you are travelling to, you will need to have these at a private travel clinic.	

Appointment Required?:	YES  - 10 mins    [   ]	YES - 20 mins      [   ]
                                                  NO APPT NEEDED – Vaccs up to date [   ]  or 
                                                                                 Needs to go to Travel Clinic [   ]

Further information  e.g. weight of child	

Signed by:                                                                             Position                                             Date	

Updated December 2019