testing Travel Risk Assessment New2 Personal Details Name: * Date of Birth: * Today's Date: * Contact Phone Number: * Contact Email Address: * Travel Details Departure Date: Duration: Country/Countries to be visited: Away from medical help at destination? If so, how remote? Future Travel Plans: Type of Trip: Business Pleasure Other Holiday Type: Package Self Organised Backpacking Camping Cruise Trekking Other Accommodation: Hotel Relatives or family home Other Travelling With: Alone With Family or Friend In a Group Staying in Area Which Is: Urban Rural Altitude Planned Activities: Safari Adventure Other Personal Medical History Do you have any recent or past medical history of note? (including diabetes, heart or lung condition) Yes No Please specify: List any current or repeat medication: Do you have any allergies? e.g. to eggs, antibiotics, latex, nuts etc. Yes No Please specify: Have you ever had a serious reaction to a vaccine given to you before? Yes No Please provide details: Does having an injection make you feel faint? Yes No Do you or any of your close family have epilepsy? Yes No Please specify: Do you have any history of mental illness? (including depression or anxiety) Yes No Please specify: Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Yes No Please specify: Women only - Are you pregnant or planning pregnancy or breastfeeding? Yes No Please specify: Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this? Yes No Please advise 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 Polio Diptheria Typhoid Hepatitis A Hepatitis B Meningitis Yellow Fever Influenza Rabies Japanese Encephalitis Cholera Malaria Tablets Other Tetanus DD/MM/YYYY Polio DD/MM/YYYY Diptheria DD/MM/YYYY Typhoid DD/MM/YYYY Hepatitis A DD/MM/YYYY Hepatitis B DD/MM/YYYY Meningitis DD/MM/YYYY Yellow Fever DD/MM/YYYY Influenza DD/MM/YYYY Rabies DD/MM/YYYY Japanese Encephalitis DD/MM/YYYY Cholera DD/MM/YYYY Malaria Tablets DD/MM/YYYY Other Details and Date (DD/MM/YYYY) Travel Advice and Leaflets Given As Per Travel Protocol Food, water and personal hygiene advice Travellers' diarrhoea Insect bite prevention Animal bites Insurance Air travel Websites Blood and bodily fluid infection risks e.g. Hepatitis B Travel record card supplied Accidents Sun and heat protection SMS vaccines reminder set up Chloroquine and proguanil Antovaguone and proguanil Chloroquine Mefloquine Doxycycline Malaria Advice Leaflet given For discussion when risk assessment is performed within your appointment. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. Signed: Date: Submit
