Lakeside Medical Practice

TRAVEL RISK ASSESSMENT FORM

Please complete this form prior to your travel appointment and return to reception

PERSONAL DETAILS:
Name:	
Date of Birth:                                       Male:  _____        Female:   _____	
Telephone Number:                                       Mobile Number:	
Email:	
DATES OF TRIP:
Date of Departure:
Return date or overall length of trip:	
ITINERARY & PURPOSE OF VISIT:
  Country 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/             Other
                                                               Family Home
	
4   Travelling:                     Alone                    With Family/         In a group
                                                               Friend
	
5   Staying in 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:

	
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?
	
FEMALES ONLY:  Are you pregnant or planning pregnancy 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 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?

                                 Previous Vaccine                        Date Given
                                                                                   .please tick
	
Tetanus	
Polio	
Diphtheria	
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.

Signed:                                                              Date:

FOR PRACTICE USE ONLY –
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 & LEAFLETS GIVEN AS PER TRAVEL PROTOCOL:
                                                                  YES                     NO	
Food, water and personal hygiene advice	
Travellers’ diarrhoea	
Hepatitis B, C and HIV	
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:
                                                                  YES                     NO	
Chloroquine and Proguanil	
Atovaquone + Proguanil (Malarone)	
Chloroquine	
Mefluoquine	
Doxycycline	
Malaria advice leaflet given	
Further Information:
eg weight of child

Signed By:                                Position:                          Date: