9 King Edward Street ~ Pre Travel Risk Assessment Form

Please complete this form prior to your appointment and return it to the surgery. This information will help your nurse/ doctor to assess your travel health needs for your trip.

Name: / Tel:
Date of Birth: / Male: / Female:
Date of travel: / Date of return:

Destination: include all countries you will visit and any you will be passing through.

Country to be visited
area/ region / Length of stay / Type of accommodation / Travelling to remote areas/ away from medical help?

Type of travel: circle that which best describes the details of your trip.

Reason for travel / business / pleasure / other
Type of holiday/ travel / package
self organised / cruising
camping / trekking
backpacking
Are you travelling with / family / group / alone
Planned activities / leisure / adventure / safari

Medical History: do any of the following apply to you? (please list any medicines you take)

Yes / No / Details
Allergies (include food, medication)
A previous reaction to any vaccine
Anaemia
Bleeding/ clotting disorders
Heart disease
Diabetes
Disability
Epilepsy/ seizures
Gastrointestinal (stomach) problems
Liver problems
HIV/ AIDS
Immune system condition
Mental health issues (eg depression)
Neurological (nervous system) illness
Kidney problems
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions
Women only Date of last period:
Are you pregnant, breastfeeding or planning a pregnancy ? Yes No

Vaccination History: please tick any travel vaccine that you have had previously.

Travel Vaccine / ü / Date(s) given if known / Travel Vaccine / ü / Date(s) given if known
Tetanus / Meningitis
Polio / Rabies
Diphtheria / Yellow Fever
Hepatitis A / Japanese B Encephalitis
Hepatitis B / Tick-borne Encephalitis
Typhoid / Influenza

Malaria: List any malaria tablets you have previously taken. If you cannot remember the name then please give details of the countries visited.

1.
2.
3.

Anything else: Please give any further information that you feel may be relevant.

Remember:

Allow plenty of time for a pre-travel consultation, book an appointment with your nurse/ doctor at least 6 weeks before you travel.
A dental check-up before you travel may prevent problems while you are away.
Take out adequate insurance for your destination and activities. A European health Insurance Card (EHIC) entitles you to free or reduced cost medical care in most EU countries. You can apply for one free of charge online (www.dh.go.uk), by phone (0845 606 2030), or by post using a form from the Post Office.
Pack a first aid kit (and a sterile kit of emergency equipment if you will be in remote areas).
Find out about the place you are travelling to. The Foreign and Commonwealth Office website (www.FCO.gov.uk) contains information and up to date travel advice.

I have received travel information and advice on the risk and benefits of the vaccines recommended and have had the opportunity to ask questions.

I consent to the vaccines being given.

Signed: Date:

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For Health Professional Use only
Discussed (ü) / Comments / Discussed (ü) / Comments
Medical preparation / Vector-borne risks
Journey risks / Air-borne risks
Safety risks / Sexual health risks
Environmental risks / Skin health
Food & water risks / Psychological health