CHEWS 2 TRAVEL 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 Name: Date of birth: Male ( ) Female ( ) Easiest contact telephone number: e.mail 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? 1 2 3 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 Typhoid Cholera Tetanus Diphtheria Polio Meningitis ACWY Yellow Fever Rabies Japanese B Encephalitis Other 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)
2010 Prohibited List What major changes does the 2010 List of Prohibited Substances and Methods include compared to the 2009 List? The List reflects the latest scientific advances. Several of the changes to be implemented in 2010 will allow anti-doping organizations to manage a number of substances and methods in a significantly more administrative- and cost-effective way. In