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Travel consultation risk assessment form

Oughtibridge Surgery
TRAVEL QUESTIONNAIRE
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. Personal details

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 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

3. Accommodation
4. Travelling
5. Staying in area Urban
6. Planned activities Safari
Personal medical history
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?
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

Vaccination History
Have you ever had any of the following vaccinations / malaria tablets and if so when?
Tetanus
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
Patient Name:

Travel risk assessment performed Yes [ ] No [ ]
TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
Disease protection
Further information
TRAVEL ADVICE AND LEAFLETS GIVEN AS PER TRAVEL PROTOCOL

personal hygiene advice Insect bite prevention
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
Chloroquine and proguanil

FUTHER INFORMATION

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

Source: http://www.oughtibridgesurgery.co.uk/prg/Travel%20Questionnaire.pdf

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