Billingshurst Surgery Travel Risk Assessment Form (Page 2 of 2) in pdf

Do you or any close family members have epilepsy?

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Do you have any history of mental illness, including depression or anxiety?

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Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

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Have you (in the last month) had any other vaccination?

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Do you have a Thymus disorder – including Thymoma, Thymectomy, Myasthenia Gravis or

George Syndrome?

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Women only: Are you pregnant or planning pregnancy or breast feeding?

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Have you taken out travel insurance, and if you have a medical condition, informed the insurance company?

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Please give any further information that may be relevant, including any future travel plans.

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Vaccination history

Have you ever had any of the following vaccinations/malaria tablets, and if so, when?

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Tetanus

Polio

Diphtheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Malaria tablets

Other

Name of ‘other’ vaccines:

_____________________________________________________________________________________________

For discussion when risk assessment is performed within your appointment:

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 have been advised that may be charged a fee for some of these

vaccinations. I consent to the vaccines being given.

Signed:

Date:

Billingshurst Surgery Travel Risk Assessment Form Page 2