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The Maples Health Centre NHS GP Surgery in Hertfordshire

Travel risk assessment

Section

Address:

GP

GP Address (including postcode)

GP Phone Number

Travel Details

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:

Travelling:

Alone

With family / friend

In a group

Type of trip:

Package Holiday

Immigration

Voluntary/Charity Work

Cruise

Organised Adventure

Elective/Student

Business 3 Months

Backpacking

Aid Worker

Visiting Family/Friends

Self Organised

Staying in area which is:

Urban

Rural

Altitude

Beach

Accommodation:

Good

Basic

Poor

Not known

Occupation/Activities planned:

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?

Yes

No

Don’t Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Don’t Know

Are you pregnant or planning pregnancy or breast feeding?

Please write below any further information which may be relevant:

Vaccination History

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? *

Please note: Some vaccines/Malaria Tablets are not covered by the NHS and will incur a charge; this will be discussed before the vaccines are given. There may be a charge for private patients.

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:

FOR OFFICIAL USE

Patient name

Patient advised of possible private charge?

Yes

No

Travel Risk Assessment performed?

Yes

No

Travel vaccines recommended for this trip:

Hepatitis A

Hepatitis B*

Option 3

Cholera

Tetanus

Diphtheria

Polio

MMR (Measles, Mumps, Rubella)*

Meningitis ACWY*

Yellow Fever*

Rabies*

Option 12

OtherOther

*Possible private cost, not covered by NHS

Malaria Prevention advice and malaria chemoprophylaxis*

Chloroquine and proguanil

Chloroquine

Doxycycline

Atovaquone + Proguanil

Mefloquine

Malaria advice leaflet given

Travel Advice/Risks Discussed/Leaflets given

Bite Avoidance

Food/Water/Hygiene

Blood Borne Viruses

Rabies

Traveler’s Diarrhoea

Schistosomiasis

Insurance/Accidents

Sun Protection

Air Travel

Bodily Fluid Injections

Other (please specify)Other (please specify)

Further Information:

Completed by:

Date:

If you are human, leave this field blank.

Sending

Δ

Vancouver Road
Broxbourne
Herts
EN10 6FD

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01992 450040

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