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Appendix 2: travel risk assessment form

Travel Health Risk Assessment Form

Please complete page 1 & 2 prior to your travel appointment and bring all 3 pages to the Travel Nurse.
Personal details
Name:
_____________________________________________________________________________________________________
Date of Birth:
_____________________________________________________________________________________________________ Easiest contact telephone number: _____________________________________________________________________________________________________ E.mail:
_____________________________________________________________________________________________________
GP name and address if not enrolled at this medical practice:
_____________________________________________________________________________________________________
Date of Departure……………………………………………
Overall length of trip……………………………….

Itinerary and purpose of visit

Country to be visited
_____________________________________________________________________________________________________ 1.
_____________________________________________________________________________________________________
2.
_____________________________________________________________________________________________________
3.
_____________________________________________________________________________________________________
4.
_____________________________________________________________________________________________________
5.
_____________________________________________________________________________________________________
6.
_____________________________________________________________________________________________________
Please circle the descriptions that best describe your trip
1.
_____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. Other………………………………. _____________________________________________________________________________________________________ 4. _____________________________________________________________________________________________________ 5. _____________________________________________________________________________________________________ 6. _____________________________________________________________________________________________________
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?

Patient Name:

Date of Birth:

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 of 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? If you have a medical condition, have you informed the insurance company about this?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Please give any further information 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?
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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:
For official use


Patient name: Authorising Doctor………………………………………………………

Travel risk assessment performed Yes [ ] No [ ] Authorisation for Nurse to administer vaccination.
Signed……………………………………………………………………. _____________________________________________________________________________________________________
Travel vaccines recommended for this trip
Disease protection Recommended Further information

Hepatitis A
_____________________________________________________________________________________________________
Hepatitis B
_____________________________________________________________________________________________________
Typhoid
_____________________________________________________________________________________________________
Cholera
_____________________________________________________________________________________________________
Tetanus/Diptheria
_____________________________________________________________________________________________________
MMR
_____________________________________________________________________________________________________
Polio
_____________________________________________________________________________________________________
Meningitis ACWY
_____________________________________________________________________________________________________
Yellow Fever
_____________________________________________________________________________________________________
Rabies
_____________________________________________________________________________________________________
Japanese B Encephalitis
_____________________________________________________________________________________________________
Other Travel Record card supplied
_____________________________________________________________________________________________________
Travel advice and/or leaflets given as per travel protocol

Food, water and personal hygiene advice Travellers diarrhoea Hepatitis B, C and HIV _____________________________________________________________________________________________________ Insect bite prevention Rabies Accidents Insurance Air travel _____________________________________________________________________________________________________ Sun and heat protection Hajj travel Yellow Fever Blood borne virus _____________________________________________________________________________________________________ Global Traveller Checklist Malaria Altitude sickness Cruise ship travel _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Malaria prevention advice and malaria chemoprophylaxis

Atovaquone + proguanil (Malarone) Chloroquine Mefloquine Doxycycline
_____________________________________________________________________________________________________
Further information
e.g. weight of child
Signed by:

Source: http://www.moorhousemedical.co.nz/resources/file/Travel%20Health%20Risk%20Assessment%20Form.pdf

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