Travel consultation risk assessment form
Please complete this form up to 12 weeks before you travel and return to reception. The nurse will look at the form and you will be contacted.
Date of birth:
[ ] Female
Easiest contact telephone number
Dates of trip
Date of Departure
Return date or overall length of trip
Itinerary and purpose of visit
Country to be visited
Length of stay
Away from medical help at
destination, if so, how remote?
Please tick as appropriate below to best describe your trip
1. Type of trip
2. Holiday type
5. Staying in area
6. Planned activities
Personal medical history
Do you have any recent or past medical history of note? (including diabetes, heart or lung
List any current or repeat medications
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 feint?
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 planning pregnancy or breast feeding?
Have you taken out travel insurance and if you have a medical condition, informed the
insurance company about his?
Please write below any further information which may be relevant
Have you ever had any of the following vaccinations / malaria tablets and if so when?
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. Payment for vaccinations is by
cash or cheque.
Signed __________________________________________ Date ________ For official use
Travel risk assessment performed Yes [ ] No [ ] TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
TRAVEL ADVICE AND LEAFLETS GIVEN AS PER TRAVEL PROTOCOL
personal hygiene advice Insect bite prevention
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
Chloroquine and proguanil
e.g. weight of child
Signed by: Position: Date:
Now scan this form into the patient’s record on the computer for evidence of best practice
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Betegtájékoztató: Információk a felhasználó számára Rennie Deflatine rágótabletta kalcium-karbonát, magnézium-karbonát, szimetikon Mielőtt elkezdi szedni ezt a gyógyszert, olvassa el figyelmesen az alábbi betegtájékoztatót, mely az Ön számára fontos információkat tartalmaz. Ezt a gyógyszert mindig pontosan a betegtájékotatóban leírtaknak, vagy az Ön ke