Norwich Practices HC - GMS
Travel risk assessment form
To be completed by traveller prior to makingappointment
Name / Date of Birth:Contact details / Telephone:
Mobile:
Date of Departure
Date of Return
Travelling to? / Please give as much detail as possible including cruise reference numbers.
Duration of stay in each destination
Duration of trip / If multiple destinations, please try to list countries visited in order
Living conditions / Tent/ motorhome/ hostel/ hotel/ family home/ safari lodge/ other…
Type of trip / Please circle: Package holiday/ cruise/ business/ organised adventure/ backpacking/ voluntary or charity work/ visiting friends or relatives/ elective/ other
Medical history
Current:
Previous: / Very important to bring record of any vaccines ever had
Current medication
(please list all, including the contraceptive pill and non prescription medicines)
Allergies?
Any reaction to previous vaccines? / Yes or no and which if known
Have you ever taken any anti-malarials and which?
Please post completed forms to: Travel Clinic, Norwich Practices Health Centre, Rouen House, Rouen Road, Norwich, NR1 1RB
Please allow at least 48 hours before contacting us to make an appointment on 01603 677500
PLEASE SEE REVERSE
Any trip abroad you are planning should begin with a Risk Assessment. This may indicate that you require a number of vaccines or products to prevent illness while you are away. Your GP Practice or Travel Agent may have advised you to seek advice on vaccine requirements for your destination.
The Practice Nurse is able to carry out a basic assessment and give advice. Should you be planning to visit multiple destinations, or fall into another ‘high risk traveller’ category they will advise you to consider booking an appointment with a Private Travel Medicine Practitioner.
There are 5 vaccines for travel purposes which are available free of charge on the NHS, these are Tetanus, Diphtheria, Polio, Hepatitis A and Typhoid. All other Travel vaccines and products such as anti-malaria pills are only available privately and will have to be paid for.
The practice nurse should indicate which vaccines to consider for your chosen destination and where to obtain these. Vaccines are not usually given at the initial risk assessment consultation.
Lesly Weston
GMS Lead Nurse