Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form in plenty of time before your journey and that you book an appointment 8-10 weeks in advance.

Travel Risk Assessment form

Travel Risk Assessment form

If you are human, leave this field blank.

Full Name *

Date of birth *

Please use this date format: DD/MM/YYYY.

First Choice Phone Number:

Second Choice Phone Number:

Email Address *

Address

Gender *

Male

Female

Registered GP Practice *

Aston Clinton

Bedgrove

Wendover

OtherOther

Date of Trip

Please use this date format: DD/MM/YYYY.

Overall Length of Trip

Please give details of travel destination(s) to be visited, length of stay, how remote you'll be from medical help and any airport transit *

Please tick as appopriate below to best describe your trip

Type of trip

Business

Pleasure

Other

Holiday type

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

Accommodation

Hotel

Relatives / family home

Other

Type of Area

Urban

Rural

Altitude

Planned activities

Safari

Adventure

Other

Do you have any recent or past medical history? (including diabetes, heart, lung, operations etc)

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?

Do you or any close family members have epilepsy?

Do you have any history of 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?

Yellow Fever

Polio

Jap Enceph

Typhoid

Tetanus

Hepatitis B

Hepatitis A

Diptheria

Rabies

Influenza

Meningitis

Tick Borne

Other / Malaria tablets

Which year did you have the Yellow Fever vaccination? *

Which year did you have the Polio vaccination? *

Which year did you have the Jap Enceph vaccination? *

Which year did you have the Typhoid vaccination? *

Which year did you have the Tetanus vaccination? *

Which year did you have the Hepatitis B vaccination? *

Which year did you have the Hepatitis A vaccination? *

Which year did you have the Diptheria vaccination? *

Which year did you have the Rabies vaccination? *

Which year did you have the Influenza vaccination? *

Which year did you have the Meningitis vaccination? *

Which year did you have the Tick Borne vaccination? *

If 'Other / Malaria tablets' please list here: *

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

Signed *

Please write your name. I confirm I am fit and well. I have no reason to think that I might be pregnant. I give my consent to the vaccines being given.

Date

Please use this date format: DD/MM/YYYY.

Certain vaccinations/courses will incur a charge, payment must be made prior to administration.
N.B. If malaria tablets are required there is a separate private prescription charge.

For Official Use only

TRAVEL VACCINES RECOMMENDED FOR THIS TRIP AND COST

Disease protection	Yes	No	Discuss	Disease Protection	Yes	No	Discuss
Hepatitis A				Yellow Fever*			£60.00
Typhoid				Meningitis ACWY*			£70.00
Tetanus				Rabies* (course)			£180.00
Diphtheria				Hepatitis B* (course)			£120.00
Polio				Japanese Enceph* (course)			£170.00
Tickborne Enceph* (course)			£180.00	Other

Consultation only regarding Malaria

Yes

No

Malaria tablets or discussion required

Yes

No

Nurse Appointment time

10 mins

20 mins

30 mins

Or ________ mins with partner

Please make your appointment at least _________ weeks prior to travel in travel clinic.

Amount Due:

Signed by:

Date:

Position: