Travel risk assessment form

Please be aware that sometimes a charge can be incurred for travel advice and some vaccines. You will be advised by the Practice Nurse of any charges, as this is not considered core NHS work. Please complete this form prior to your travel appointment.
Personal details
Date of birth: Male ( ) Female ( )
Easiest contact telephone number:
Dates of trip
Date of departure:
Return date or overall length of trip:
Itinerary and purpose of visit
Country(ies) to be visited
Length of stay
Away from medical help at destination? If so, how remote?
Please circle the descriptions that best describe your trip
1. Type of trip: Business Pleasure Other
2. Holiday type: Package Self-organised Backpacking
Camping Cruise ship Trekking
3. Accommodation Hotel Relatives/family home Other
4. Travelling Alone With family/friend In a group
5. Staying in an area which is Urban Rural Altitude
6. Planned activities Safari Adventure Other
Personal Medical History
Do you have any recent or past medical history of note? This includes diabetes,
heart or lung conditions, thymus disorder:
List any current or repeat medications:
Chew Medical Practice October 2010 (updated) CHEWS 2 TRAVEL
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you ever had a serious reaction to a vaccine given to you before
Does having an injection make you feel faint?
Do you or any close family members have epilepsy
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only: are you pregnant 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
Vaccination History

Have you ever had any of the following vaccinations/malaria tablets, and if so when?
Typhoid □ Hepatitis A □ Hepatitis B □ Meningitis □ Yellow Fever □ Influenza □ Rabies □ Jap B Enceph □ Tick Borne □ Other Malaria tablets For discussion when risk assessment is performed within your 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. Chew Medical Practice October 2010 (updated) CHEWS 2 TRAVEL
Signed: Date:
For official use
Patient name:
Travel risk assessment performed Yes □ No □
Travel vaccines recommended for this trip
Disease protection Yes No Further information

Hepatitis A

Hepatitis B
Meningitis ACWY
Yellow Fever
Japanese B Encephalitis
Travel advice and leaflets given as per travel protocol
Food water and personal hygiene advice □ Travellers’ diarrhoea □ Insect bite prevention □ Animal bites □ Accidents □ Insurance □ Air Travel □ Sun and heat protection □ Hajj travel □ Travel record card supplied □ Websites □ Other □
Malaria prevention advice and malaria chemoprophylaxis
Chloroquine and Proguanil □ Atovaquone + Proguanil (malarone) □ Chloroquine □ Mefloquine □ Doxycycline □ Malaria advice leaflet given □
Further information e.g. weight of child
Signed by: Position Date
Chew Medical Practice October 2010 (updated) CHEWS 2 TRAVEL
Please add any additional information that you may feel would assistance the nurse in giving you the best travel advice for your travel requirements. Chew Medical Practice October 2010 (updated)


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