Ilex View Medical Practice

ILEX VIEW MEDICAL PRACTICE

“Promoting good health”

Travel risk assessment form

Please complete this form and return it to the surgery
AT LEAST 2 WEEKS BEFORE your appointment.

The information you provide will enable the Practice Nurse to assess your travel health needs before your attendance and enable her to make sure that you are fully prepared for your trip.

OFFICE USE ONLY / Appointment on: / With Diane / Elaine

Personal details

Name / Date of birth
Daytime telephone no. / Sex / Male / Female
Mobile telephone no.

Dates of trip

Date of departure
Return date oroverall length of trip

Itinerary and purpose of visit

Countries to be visited
Area/town/cities to be visited
Length of stay
Will you be away from medical help at destination? If so, how remote?

Please circle the descriptions that best describe your trip

Type of trip / Business / Pleasure / Other
Holiday type / Package / Self-organised / Backpacking
Camping / Cruise ship / Trekking
Accommodation / Hotel / Relatives/family home / Other
Travelling / Alone / With family/friend / In a group
Staying in area which is / Urban / Rural / Altitude
Planned activities / Safari / Adventure / Other

Personal medical history

1.Do you have any recent or past medical history of note? This includes diabetes, epilepsy,
heart or lung conditions, thymus disorder or removal of your spleen.Y / N

If yes, please give details ……………………………………………………………………………………….

2.List any current or repeat medications ….…………………………………………………………………

3.Do you have any allergies for example to eggs, antibiotics, nuts?Y / N

4.Have you ever had a serious reaction to a vaccine given to you before?Y / N

5.Have you recently undergone radiotherapy, chemotherapy or steroid treatment?Y / N

6.Female patients only:Are you pregnant or planning pregnancy?Y / N

Are you breast feeding?Y / N

7.Have you taken out travel insurance?Y / N

Have you informed the insurance company about any medication conditions you have?Y / N

8.Please give any further information that may be relevant, including any further travel plans.

Office use only

Travel risk assessment performed Yes / No

Travel vaccines recommended for this trip

Disease protection / Yes / No / Further information
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Other

Malaria prevention advice and malaria chemoprophylaxis

Chloroquine and proguanil / Atovaquone + proguanil (Malarone)
Chloroquine / Mefloquine
Doxycycline / Malaria advice leaflet given

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