Travel Risk Assessment Travel Risk Assessment Full Name * Date of Birth: * Please use this date format: DD/MM/YYYY. Phone Number: Email Address: * Any responses we send will go to this email address. Gender: Male Female 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: Package Self organised Backpacking Camping Cruise ship Trekking 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? Tetanus Polio Diptheria Typhoid Hepatitis A Hepatitis B Meningitis Yellow Fever Influenza Rabies Jap B Enceph Tick Borne Other / 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: * I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent - it may take up to 3 working days before I receive a reply.
Grosvenor Place Surgery