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Travel consultation risk assessment form
THE PENTLANDS MEDICAL CENTRE TRAVEL RISK ASSESSMENT FORM
Please complete this form prior to your travel appointment and return to reception
There is a standard charge of £30 for most travel work for patients 16yrs and over
This fee covers the time required to review your travel itinerary, check your previous
vaccinations and medical history and establish what the current recommendations are for health protection for travel to your destination. The fee also covers any nurse appointments,
private prescriptions and advice you may need.
Date of birth:
[ ] Female
Easiest contact telephone number
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
5. I am staying in an
area which is…
6. Planned activities
Personal medical history Do you have any recent or past medical history of note? (including diabetes, heart or lung
conditions, thymus disorder )
List any current or repeat medications (Continue overleaf if necessary)
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 faint?
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 this?
Please write any further information which may be relevant (Continue overleaf if necessary)
Have you ever had any of the following vaccinations / malaria tablets and if so when?
When you attend your appointment you will receive information on the risks and benefits of the vaccines suggested. We will ask for your verbal consent before any vaccinations are given.
The fee for the Pentlands Medical Centre travel service is £30 (under 16’s free)
Immunisation against Rabies, Hepatitis B or Japanese B encephalitis all require
three further Nurse appointments. There is an ADDITIONAL fee of £30 for this.
PLEASE SEE TRAVEL CLINIC INFORMATION SHEET FOR FULL DETAILS OF FEES
We would advise you to visitfor useful advice on
travel health including food and water hygiene, care in the sun and bite
Signed __________________________________________ Date ______________
For official use
Travel risk assessment performed Yes [ ] No [ ]
TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
TRAVEL ADVICE AND LEAFLETS GIVEN AS PER TRAVEL PROTOCOL
personal hygiene advice Insect bite prevention
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
Chloroquine and proguanil
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
Acarbose Acebutolol Acetazolamide Acetylsalicylic Acid Adderall Adenosine Alprazolam Alprazolam Alprostadil Amiodarone Amiodarone Amitriptyline Amlodipine Amlodipine and Atorvastatin Amlodipine and Benazepril Amobartibal Amoxapine APAP / Butalbital / Caffeine Aripiprazole ASA + Persantine Aspirin / Butalbital / Caffeine Aspirin / Cod
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