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Travel consultation risk assessment form

87/89 Prince of Wales Road, London NW5 3NT TRAVEL APPOINTMENT INFORMATION
Make an appointment with the nurse early. 6-8 weeks before travel is ideal.
Children – please bring their red book or details of any injections they have
received.
Adults – bring any vaccination / travel record cards.
Don’t leave making an appointment to the last minute; an appointment may
not be available. Late vaccinations could mean you are not fully protected.
Also you may have to use a private travel clinic and pay for your
vaccinations.
Vaccines available free on the NHS:
Tetanus / diphtheria / polio / hepatitis A / typhoid

Vaccines which you have to pay for:
CHEQUE OR CASH ONLY PLEASE
Yellow fever £50
Meningitis ACYW £45
Hepatitis B £100 for a full course £35 for a booster
Rabies £130 for a full course £45 for a booster

Vaccines that are only available at a travel clinic:
Japanese encephalitis & Tick bourne encephalitis
Malaria tablets are not available on an NHS prescription. We can provide
private prescriptions for appropriate malaria prophylaxis.
Plan early so we can give you the best protection and advice for a happy
and healthy trip. If you miss your travel appointment we will not be able to
offer you another one for 3 months. Please remember to cancel your
appointment in advance to avoid this happening.
Reception Appointment date
Prince of Wales Group Practice
TRAVEL RISK ASSESSMENT FORM
Please complete this form prior to your appointment and return to reception
PLEASE BRING ANY IMMUNISATION RECORD CARDS AND / OR YOUR
CHILD HEALTH RECORD / RED BOOK TO YOUR TRAVEL APPOINTMENT

Personal details

Date of birth:

Male [ ] Female [ ]
Easiest contact telephone number
E mail
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
3. Accommodation
4. Travelling
5. Staying in area Town
6. Planned activities Safari
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
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 his?
Please write below 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
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 __________________________________________ Date ________
TRAVEL ADVICE AND
LEAFLETS GIVEN
AS PER TRAVEL PROTOCOL
………………………………… ASSESSMENT ………………………………….
COMPLETED

VACCINE
ADVISED DECLINED AUTHORISED BY

MALARIA PROPHYLAXIS ADVISED – CHILDS WEIGHT - KG

NOT
CHLOROQUINE DOXYCYCLINE MALARONE MEFLOQUINE

Source: http://www.princeofwalesgrouppractice.nhs.uk/website/F83018/files/Travel_risk_assessment_form_prince_of_wales_new_02.09.2013.pdf