Travel risk assessment

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Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country to be visited, length of stay, and how remote you’ll be from medical help:

Type of trip:

Business

Pleasure

Other

Holiday type:

Accommodation:

Hotel

Relatives / family home

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Other

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)

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?

Yes

No

Don’t Know

Does having an injection make you feel faint?

Yes

No

Don’t Know

Do you or any close family members have epilepsy?

Yes

No

Don’t Know

Do you have any history or mental illness including depression or anxiety?

Yes

No

Don’t Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Don’t Know

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Yes

No

Don’t Know

Are you pregnant or planning pregnancy or breast feeding?

Please write below any further information which may be relevant:

Have you ever had any of the following vaccinations / malaria tablets?

Which year did you have the Tetanus vaccination?

Which year did you have the Polio vaccination?

Which year did you have the Hepatitis A vaccination?

Which year did you have the Hepatitis B vaccination?

Which year did you have the Meningitis vaccination?

Which year did you have the Yellow Fever vaccination?

Which year did you have the Influenza vaccination?

Which year did you have the Rabies vaccination?

Which year did you have the Jap B Enceph vaccination?

Which year did you have the Tick Bourne vaccination?

Which year did you have the Diptheria vaccination?

Which year did you have the Typhoid vaccination?

If “Other / Malaria tablets” please list here:

Which year did you have the other vaccination / malaria tablets?

Signed:

Please write your name. 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.

Date:

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