MITCHELDEAN SURGERY

TRAVEL ASSESSMENT FORM

Please complete this side only as fully as possible

Personal Details
Full Name: / Date of Birth:
Contact Telephone No: / Gender:
Your Itinerary and Purpose of Visit: (please indicate exact location or region)
Departure Date:
Return Date (or trip length):
Country(ies) to be visited
(and length of stay) / 1. / 2.
3. / 4.
Additional Travel Plans
Away from medical help at destination? If yes, how remote?
Please tick below as appropriate to best describe your trip:
1. / Type of Trip /  Business /  Pleasure /  Other
2. / Holiday Type /  Package /  Self-Organised /  Back-Packing
 Camping /  Cruise Ship /  Trekking
3. / Accommodation /  Hotel /  Relatives’ Home /  Other
4. / Travelling /  Alone /  With Family/Friend /  In a Group
5. / Staying in area /  Urban /  Rural /  Altitude
6. / Planned Activities /  Safari /  Adventure /  Other
Personal Medical History (please use a separate sheet if necessary)
1. / Do you have any recent or past medical history of note (including diabetes, heart or lung conditions /  Yes /  No
2. / List any current or repeat medications (or bring list with you)
3. / Do you have any allergies? (eg, eggs, antibiotics, nuts) /  Yes /  No
4. / Have you ever had a serious reaction to a vaccine before? /  Yes /  No
5. / Does having an injection make you feel faint? /  Yes /  No
6. / Do you or any close family members have epilepsy? /  Yes /  No
7. / Do you have any history of mental illness, including depression or anxiety? /  Yes /  No
8. / Do you have any kidney or liver problems? /  Yes /  No
9. / Have you recently undergone radiotherapy, chemotherapy or steroid treatment? /  Yes /  No
10. / Women only: are you pregnant, planning a pregnancy or breastfeeding? /  Yes /  No
11. / Have you taken our travel insurance? If yes, and you have a medical condition, have you informed your Insurance Company about this? /  Yes /  No
12. / Please add any further information which may be relevant (eg, YES answers above)
Vaccination History
Have you ever had any of the following vaccinations/malaria tablets. If yes, please insert date.
Diphtheria / Influenza / Rabies / Tick Borne
Hepatitis A / Meningitis / Tetanus / Typhoid
Hepatitis B / Polio / Other / Other
Malaria Tablets / Jap B Enceph / Yellow Fever

For Surgery Use Only:

Patient Full Name:
Travel Risk Assessment Performed: /  Yes /  No / OPAS PIN:
Travel Vaccines Recommended for this Trip:
Disease Protection / Yes / No / Further Information
BCG/Mantoux Test
Cholera
Hepatitis A
Hepatitis B
Japanese B Encephalitis
Measles, Mumps, Rubella
Meningitis ACWY
Rabies
Seasonal Influenza
Tetanus, Diphtheria, Polio
Tick Borne Encephalitis
Typhoid
Yellow Fever
Travel Advice and Leaflets given as per Travel Protocol
Food, Water & Personal /  / Travellers’ Diarrhoea /  / Hepatitis B & HIV / 
Insect Bite Prevention /  / Animal Bites /  / Accidents / 
Insurance /  / Air Travel /  / Sun & Heat Protection / 
Websites /  / Travel Record Supplied /  / 
 /  / 
 /  / 
Malaria Prevention Advice & Malaria Chemoprophylaxis
Chloroquine & Proguanil /  / Antaquone & Proguanil (Malarone) / 
Chloroquine /  / Mefloquine (Larium) / 
Doxycycline /  / Malaria Advice Leaflet given / 
Further Information

Practitioner Name:Date:

Declaration

I have no reason to think that I might be pregnant. I have received the 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 and the charges as outlined in the Travel Health Advice Leaflet which I have received.

Patient Signature:Date:

Patient Full Name: