SHERINGHAM MEDICAL PRACTICE
TRAVEL RISK ASSESSMENT FORM
Please complete this form prior to your travel appointment and return to reception if you have a pre-booked appointment, or bring along with you if you are attending the walk-in travel clinic.
You must advise us at least 8 weeks before your departure date.
This form can be printed via the "Documents" page
Personal Details|
Name: |
|
||
|
Date of Birth: |
|
Sex: |
M / F please circle |
|
Address: (including postcode) |
|
||
|
Contact Number: |
|
||
|
Email:
|
|
||
Dates of Trip
|
Date of Departure |
|
Return Date |
|
Overall length of trip |
|
Itinerary and Purpose of Visit
|
Country to be visited (including stopovers and touchdowns) |
Length of Stay |
Away from medical help at destination? If so how remote. |
|
1.
|
|
|
|
2.
|
|
|
|
3.
|
|
|
Please tick as appropriate below to best describe your trip (tick all that apply)
|
Type of Trip |
Business |
|
Pleasure |
|
Other |
|
Holiday Type |
Package |
|
Self-organised |
|
Beach |
|
|
Backpacking |
|
Camping |
|
Cruise Ship |
|
|
|
Trekking |
|
|
|
|
|
|
Accommodation |
Hotel |
|
Relatives/Family home |
|
Self-catering |
|
|
Other (please specify) |
|
|
||||
Travelling |
Alone |
|
With family/friend |
|
In a group |
|
Area |
Urban |
|
Rural |
|
Altitude |
|
|
Jungle |
|
Desert |
|
Wildlife |
|
|
|
Planned activities |
Safari |
|
Adventure |
|
Scuba Diving |
|
|
Other (please specify) |
|
|
||||
What vaccinations or immunisations have you had already – please give approximate dates:
|
Vaccination |
Date |
|
| 1 |
|
|
| 2 |
|
|
| 3 |
|
|
| 4 |
|
|
| 5 |
|
|
Please sign the DECLARATION
I confirm that the above details are correct to the best of knowledge
Signed: _____________________________________________
Date: ____________________
If this form is not filled out correctly or we have less than 8 weeks before your holiday when we see you – we cannot guarantee your holiday vaccination programme will be complete and you may be directed to a private travel clinic.
TO BE COMPLETED BY PRACTICE STAFF
Date received: ________________________
GP signature needed for non NHS vaccines before administration
Immunisations recommended by nurse:
|
NHS vaccine recommended |
NON NHS vaccine recommended |
GP signature |
|
|
1 |
|
|
|
| 2 |
|
|
|
| 3 |
|
|
|
| 4 |
|
|
|
| 5 |
|
|
|
| 6 |
|
|
|
DATE: ___________________________