For non-nhs vaccines, the fee for each vaccine given is £15, plus £15 for each item on a private prescription

Grantown on Spey Medical Practice
TRAVEL RISK ASSESSMENT FORM
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For non-NHS vaccines, the fee for each vaccine given is £15, plus £15 for each item on a private prescription. Fees are payable at the time of the initial consultation and can be
paid in cash or by cheque – payable to Grantown-on-Spey Medical Practice

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

Personal Details
Name:
Date of birth: male [ ] female [ ]
Easiest contact ‘phone 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 Will you be staying >24 hours away
from medical help at destination?
If so, how remote?
Please circle the descriptions that 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 Relatives/family home Other
4 Travelling Alone With family/friend In a group
5 Staying in area Urban Rural Altitude
which is:
6 Planned activities Safari Adventure Other
Personal medical history
Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions, thymus
disorder.
List any current or repeat medications:
Do you have any allergies (for example) to eggs, antibiotics, nuts?
C:\Documents and Settings\Ian\Local Settings\Temporary Internet Files\Content.Outlook\GTDUS0RI\NEW travel form 7-9-07.doc Grantown on Spey Medical Practice
TRAVEL RISK ASSESSMENT FORM
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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 of mental illness including depression or anxiety? Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Women only: Are you pregnant or breast feeding? OR are you planning pregnancy? Have you taken out travel insurance? If you have a medical condition, have you informed the insurance company about this? Please give any further information which may be relevant, including any future travel plans. Vaccination History:
Have you ever had any of the following vaccinations/malaria tablets, and if so, when?
Typhoid  Hepatitis A  Hepatitis B  Meningitis  Yellow fever  Influenza  Rabies  Jap B Enceph  Tick borne  Have you ever taken Malaria tablets before? Declaration
For discussion when risk assessment is performed within your appointment:
I have no reason to think that I may 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:
C:\Documents and Settings\Ian\Local Settings\Temporary Internet Files\Content.Outlook\GTDUS0RI\NEW travel form 7-9-07.doc Grantown on Spey Medical Practice
TRAVEL RISK ASSESSMENT FORM
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PATIENT’S NAME:………………………………………………………………………………………………………………………….
Travel risk assessment performed:
Travel Vaccinations recommended for this trip: IMMUNISED YEAR ADVISED
DATES FOR IMMUNISATIONS TO BE
TOTAL FEES DUE

Travel Advice leaflets given:

Food water and personal hygiene advice  travellers’ diarrhoea  Hepatitis B, C and HIV 
Insect bite prevention 

Malaria Prevention Advice and malaria chemoprophylaxis:
Chloroquine and proguanil 

Further Information
e.g. weight of child

C:\Documents and Settings\Ian\Local Settings\Temporary Internet Files\Content.Outlook\GTDUS0RI\NEW travel form 7-9-
07.doc
Grantown on Spey Medical Practice
TRAVEL RISK ASSESSMENT FORM
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Signed by:
Position:
C:\Documents and Settings\Ian\Local Settings\Temporary Internet Files\Content.Outlook\GTDUS0RI\NEW travel form 7-9-07.doc

Source: http://www.grantownonspeymedicalpractice.co.uk/website/S55925/files/grantowntravel.pdf