The Guildhall  and Barrow Surgery

TRAVEL RISK ASSESSMENT FORM

Please complete this form prior to your travel appointment and return to reception.

Name:			Date of birth:
Address:			Male   (    )      Female   (    )
Easiest contact telephone number:
Date of Departure:		Return date or overall length of trip:
Country(ies) to be visited	Length of stay		Away from medical help at destination?  If so, how remote?
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Please tick as appropriate below to best describe your trip
1.  Type of trip:	Business		Pleasure		Other
2.  Holiday type:	Package		Self-organised		Backpacking
	Camping		Cruise ship		Trekking
3.  Accommodation:	Hotel		With relatives/family		Other
4.  Travelling:	Alone		With family/friend		In a group
5.  Area staying in:	Urban		Rural		Altitude
6.  Planned activities:	Safari		Adventure		Other
Further details if necessary:

Personal medical history:

Do you have any recent or recent 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 or nuts?

Have you ever had a serious reaction to a vaccine?

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?

Do you have any further relevant information?

Have you ever had any of the following vaccinations or malaria tablets?  If so, when?
Tetanus		Polio		Diphtheria
Typhoid		Hepatitis A		Hepatitis B
Meningitis		Yellow fever		Influenza
Rabies		Japanese B encephalitis		Tick-borne encephalitis
Malaria

At your appointment, before you are given your vaccinations you will be asked to declare the following:
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: