Travel Risk Assessment Form - HCP Use Only

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Patients Personal Details

Patients Patients Gender: *

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Discussions, recommendation's and vaccine's given

Risk Management Checklist

Discussed

Comments

1. Medical preparation, (including pre-existing conditions)

1. Discussed - Medical preparation, (including pre-existing conditions):

2. Journey risks

2. Discussed - Journey risks:

3. Personal safety / accidents / injuries

3. Discussed - Personal safety / accidents / injuries:

4. Environmental risks

4. Discussed - Environmental risks:

5. Food & water safety / travellers’ diarrhoea

5. Discussed - Food & water safety / travellers’ diarrhoea:

6. Vector-borne risks e.g. dengue, Zika

6. Discussed - Vector-borne risks e.g. dengue, Zika:

7. Malaria ABCD (record medication in table below):

7. Discussed - Malaria ABCD (record medication in table below)::

8. Rabies & animal bite

8. Discussed - Rabies & animal bite:

9. Sexual health / blood-borne viruses

9. Discussed - Sexual health / blood-borne viruses:

10. Skin / sun health

10. Discussed - Skin / sun health:

11. Psychological health

11. Discussed - Psychological health:

12. FGM

12. Discussed - FGM:

Vaccinations discussed today

1. Cholera

1. Cholera:

2. Diphtheria/tetanus/polio

2. Diphtheria/tetanus/polio:

3. Hepatitis A

3. Hepatitis A:

4. Hepatitis B

4. Hepatitis B:

5. Japanese encephalitis

5. Japanese encephalitis:

6. Meningitis ACWY

6. Meningitis ACWY Other: Tick-borne encephalitis:

7. Tick-borne encephalitis

7. Tick-borne encephalitis:

8. MMR

8. MMR:

9. Rabies

9. Rabies:

10. Typhoid

10. Typhoid:

11. Yellow fever

11. Yellow fever:

12. Influenza

12. Influenza:

13. Other:

13. Other::

Childhood / UK vaccination programme up-to-date?

Childhood / UK vaccination Yes or No:

Antimalarial medication discussed today

1. Atovaquone & proguanil

1. Atovaquone & proguanil:

2. Chloroquine & proguanil

2. Chloroquine & proguanil:

3. Doxycycline

3. Doxycycline:

4. Mefloquine

4. Mefloquine:

5. Emergency standby

5. Emergency standby:

Signed & Dated

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CONTACT DETAILS

Broom Road Medical Practice
23 Broom Road
Shirley
Croydon
Surrey
CR0 8NG

Telephone: 020 8777 5511
Out-Of-Hours: 111

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