King Edward’s Medical Group
TRAVEL ASSESSMENT FORM
Please complete this form prior to your travel appointment and return to our nurses/ reception. The form will be assessed and then our nurses will advise you. Please fill this at least 8 weeks prior to your departure.
PERSONAL INFORMATION
First Name: Surname:
Date of Birth:
Male _ Female _
Prefered contact telephone number:
DATES OF TRIP:
Date of departure:
Return date or overall length of trip:
ITINERARY
Country to be visited / Length ofstay / Will you be away from medical help
at destination, if so, how remote?
PURPOSE OF TRIP
(For each section, please tick as appropriate how best to describe your trip)
Type of trip / Holiday type / Accommodation / Staying in areawhich is
Buisness / Backpacking / Hotel / Urban
Pleasure / Camping / Relatives/ Family / Rural
Package / Trekking / Other / Altitude
Self organised / Cruise Ship
Medical / Safari
Other / Adventure
Other
PERSONAL MEDICAL INFORMATION
Do you have any recent or past medical history of note?
(including diabetes, heart or lung conditions)
Yes _ No _
List any current medication not prescribed by surgery or herbal remedies routinely
Taken
Do you have any allergies, for example to eggs, antibiotics or
nuts?
Yes _ No
_
Have you ever had a serious reaction to a vaccine given to you
before?
Yes _ No _
Does having an injection make you feel faint?
Yes _ No _
Do you have any history of mental illness including depression or
anxiety?
Yes _ No _
Have you recently undergone radiotherapy, chemotherapy or
steroid treatment?
Yes _ No _
Women: are you pregnant, planning pregnancy or breast feeding?
Yes _ No _
Have you taken out travel insurance and, if you have a medical
condition, informed the insurance company about this?
Yes _ No _
Please write below further information which may be relevant
VACCINATION HISTORY
(Please provide dates of any immunisations received outside the surgery for the diseases listed below)
Tetanus MeningitisPolio Yellow Fever
Diptheria Influenza
Typhoid Rabies
Hepatitis A Jap B Enceph
Hepatitis B Tick Borne
Other
Malaria Tablets
FOR COMPLETION PRIOR TO VACCINATION DURING APPOINTMENT
I have no reason to think that I might be pregnant, I have received information on the
risks and benefits of the vaccines recommended and have had the opportunity to ask
questions. I consent to the vaccines being given.
Signed Date
For official use:
Travel risk assessment performed Yes _ No _
TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
(For each vaccine, please tick if needed and add any further information in the space provided)
Hepatitis A_Hepatitis B_
Typhoid_
Cholera_
Tetanus
Diptheria_
Polio
Meningitis ACWY_
Yellow Fever_
Rabies_
Jap B Enceph_
Other (please list
_
TRAVEL ADVICE GIVEN AS PER TRAVEL PROTOCOL
(Please tick as appropriate)
_ Food, water and personal hygiene advice
_ Traveller’s diarrhoea
_ Hepatitis B and HIV
_ Insect bite prevention
_ Animal bites
_ Accidents
_ Insurance
_ Air travel
_ Sun and heat protection
_ Websites
_ Travel record card supplied
_ Other (please list)
MALARIA PREVENTION ADVICE AND MALARIA CHEMOPROPHYLAXIS
(Please tick as appropriate)
_
Chloroquine and proguanil_ Atovaquone and proguanil (Malarone)
_ Chloroquine
_ Mefloquine
_ Doxycycline
Further Information
(e.g. weight of child)
Signed by:
Position:
Date:
.
Appointment Length: Date:
Number of Appointments (and intervals):
Cost to Patient:
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