Travel risk assessment form

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First found May 22, 2018

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Travel Risk Assessment Form
To be completed prior to appointment
Patient Details
Name
Address
Email
< ontact details>
Travel Itinerary
Dates
Country
1.
2.
3.
4.
Date of birth
NHS number
Home Telephone
Mobile Telephone
Exact location/region
Travel Information (please tick all that apply)
Type
□ Holiday
□ Business trip
□ Expatriate □ Cruise ship
Accommodation □ Hotel
□ Camping
Activities
□ Safari
□ Diving
Additional information:
City or Rural
□ Volunteer work
□ Healthcare worker
□ Hostels
□ Adventure
Length of Stay
□ Visiting friends/family
□ Pilgrimage
□ Friends/Family
Medical History
Yes
No
Details
Are you fit and well today
Severe reaction to a vaccine before
Tendency to faint with injections
Any surgical operations in the past, including e.g. your
spleen or thymus gland removed
Recent chemotherapy/radiotherapy/organ transplant
Anaemia
Bleeding /clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal (stomach) complaints
Liver and or kidney problems
HIV/AIDS
Immune system condition
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions?
Women only
Are you pregnant?
Page 1 of 2
Are you breast feeding?
Are you planning pregnancy while away?
Information on any vaccines or malaria tablets taken in the past
Tetanus/Polio/Diptheria
MMR
Typhoid
Hepatitis A
Cholera
Hepatitis B
Japanese Encephalitis
Rabies
Tick Borne
BCG
Encephalitis
Malaria Tablets
Influenza
Pneumococcal
Meningitis
Yellow Fever
Other
Allergies
Please amend this as necessary (include food, latex and medication)
<Allergies & Sensitivities>
Medications
Please amend this as necessary (include prescribed, purchased or contraceptive pill)
Acute Medication
<Medication>
Repeat Medication
<Repeat templates>
Further Information
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Other information:
Page 2 of 2
<Patient name>, <Date of birth>, <NHS number>
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