The Vauxhall Practice   	                and 	 	          Tutshill Surgery
Vauxhall Lane	 						Coleford Road
Chepstow NP16 5PZ						Tutshill NP16 5BN
Tel:  01291 636100     						Tel:  01291 637910 
Fax: 01291 627975					 	Fax: 01291 623668

Vauxhall Practice and Tutshill Surgery
Pre-Travel Risk Assessment Form

Please complete this form and return it to reception at the Vauxhall Practice or Tutshill Surgery at least 8 weeks prior to travel.  

Our Travel Specialist Practice Nurse will then assess your Travel form and telephone you to confirm what vaccinations you require inform you about charges if this is relevant and to book you an appointment in our Travel Clinic.

Our Travel Clinic normally operates on a Monday evening from Tutshill Surgery from 4pm to 6pm.  Our Dispensary is also open at this time should you require any Travel Medications.

Name
	
Date of Birth                                               Male/Female
	
Address

Daytime Telephone
	
Mobile Number
	
Email address
	
I confirm that I am happy to be contacted by any of the contact details given above.  
	
Signed                                                    Date
	
My preferred method of contact would be (please circulate below if you have a preference) 

Daytime tel                        Mobile                    Email	

Dates of Travel

Date of Travel leaving the UK
	
Date of Return to UK

Destination: Give details of the countries you will be visiting, in the correct order, including any country you may just be passing through.

Country to be visited
Area/region	Length 
of stay	Type of accommodation	Travelling to remote areas or away from medical help?	
1.
				
2.
				
3.
				
4.
				
5.
				
6.
				
7.
				
8.

Type of travel: Circle which activity best describes the purpose of your trip

Reason for Travel
	
Business
	
Pleasure	
Other	

Type of holiday/travel	
Package

Self organised	
Cruising

Camping	
Trekking

Backpacking	

Are you travelling with	
Family	
Group	
Alone	

Planned activities
	
Leisure	
Adventure	
Safari

Personal Medical History:
Give details of any conditions which may affect your travel plans
Do you have any current or past medical conditions, epilepsy, thymus disorders, cancer, HIV etc

	
List any medication that you are currently taking

	

Do you have or have you ever had any of the following:
Allergies (e.g. eggs, antibiotics)		
A previous reaction to any vaccine		
Recent Surgery		
Treatment with steroids, chemotherapy or radiotherapy		
High Blood Pressure		
Epilepsy		
Fainting		
Anxiety, depression or mental illness		

Vaccination History: Please tick any travel vaccine that you have previously been given stating when.

√ 	Travel Vaccine	Date(s) given if known	
	Tetanus		
	Polio		
	Diphtheria		
	Hepatitis A		
	Hepatitis B		
	Typhoid		
	Meningitis		
	Rabies		
	Yellow Fever		
	Japanese B Encephalitis		
	Tick Borne Encephalitis		
	Influenza		

Malaria: List the names of any malaria tablets that you may have previously taken, if you cannot remember the name of the tablet it may be useful to list the country visited.
1.
	
2.
	
3.

Please give any further information that you feel might be relevant

	

Remember:
•	Allow plenty of time for a pre-travel consultation with your practice nurse at least 6-8 weeks before you travel	
•	A dental check-up before you travel may prevent problems while you are away	
•	Take out adequate insurance for your destination and activities. A European Health Insurance Card (EHIC) entitles you to free or reduced rate medical care in most EU countries. You can apply for one free of charge online (www.dh.gov.uk), by phone (0845 6062030), or by post using a form from the Post Office	
•	Pack a first aid kit (a sterile kit of emergency equipment may be a good idea if you are going somewhere remote)	
•	Find out about the place you are travelling , the Foreign and Commonwealth Office website www.FCO.gov.uk contains information and up to date advice on travelling abroad, including information about risks in specific countries	

I have received travel information and advice on the risk and benefits of the vaccines recommended and have had the opportunity to ask questions.
I consent to the vaccines being given.

Signed: ___________________________  Date:______________