Risk Assessment form
Your risk assessment will be undertaken by Dr Ravi Gowda, Consultant in Infectious Diseases and Travel Medicine. He has decades of experience in Tropical Medicine and travel health, and receives referrals from health care professionals throughout the region.
Why do I need to fill out a risk assessment?
It is vital that we undertake an appropriate personal and destination risk assessment to ensure that any advice that we offer you is safe. Your medical condition or any medications that you are taking can potentially affect any vaccinations or medications that we may administer. So it is very important that we collect as much information as possible to reduce the risk of serious side-effects. We also need to make sure that we are able to give you appropriate advice if you are a high risk individual (for example you have a weakened immune system) So please take care in filling out this questionnaire.
Personal Details
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Email address
*
Mobile phone number
*
Landline number
Address (including postcode)
*
Gender
Male
Female
Prefer not to say
Is your appointment travel related?
Yes
No
What is the reason for your attendance today?
*
A full travel assessment
Vaccination
Malaria tablets
Medical exam
Other - please specify
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Travel Details
Date of departure
Date of departure (if you are unsure, please give an approximate date)
*
-
Day
-
Month
Year
Duration of travel
Duration of travel (if you are unsure, please give an approximate duration)
*
1 week
2 weeks
3 weeks
4 weeks
2 months
3 months
Other
Country (or countries) visiting
*
Exact locations to be visited, and length of time at each
*
Do you plan to travel abroad again in the future?
*
Yes
No
Not sure
Accommodation - please select all that apply
*
Camping
Cruise
Hostel
Hotel
Holiday resort
Residential
Unknown
Other - please specify
Purpose of your trip - please select all that apply
*
Business
Emigrating/Expat
Hajj/pilgrimage
Holiday
Non-governmental organisation work/charity
Visiting friends/relatives
Study
Work placement
Health procedure/Medical Tourism
School trip
Unknown
Other - please specify
Type of travel and activity - please select all that apply
*
Aid work/volunteer
Working in a refugee camp
Backpacking
Healthcare worker
Beach resort holiday
Rural/remote location
Safari
Contact sport
Scuba-diving
Freshwater swimming
Hiking/trekking
Mountaineering
Other extreme sport
Short leisure break
Special occasion/wedding etc
Business/work related
Visiting friends and relatives
Unknown
Other - please specify
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Medical History
Is the person being risk assessed aged less than 12 months or more than 60 years?
*
Yes
No
Are you fit and well today?
*
Yes
No
Please give details
Do you have any current acute illness with fever?
*
Yes
No
Please give details
Any allergies including food, egg, chicken protein, latex, medications, or neomycin?
*
Yes
No
Please give details
Severe/allergic reaction to a vaccine before?
*
Yes
No
Not sure
Please give details
Tendency to faint with injections?
*
Yes
No
Please give details
Have you had any surgical operations in the past, including removal of your spleen, thymus gland, cardiac surgery or open chest surgery?
*
Yes
No
Please give details
Any spleen or thymus gland problems for example, Myasthenia Gravis?
*
Yes
No
Please give details
Heart disease (e.g. angina, high blood pressure)
*
Yes
No
Please give details
Respiratory (lung) disease
*
Yes
No
Please give details
Gastrointestinal (stomach) complaints?
*
Yes
No
Please give details
Liver and/or kidney problems?
*
Yes
No
Please give details
Neurological (nervous system) illness?
*
Yes
No
Please give details
Epilepsy or seizures?
*
Yes
No
Please give details
Rheumatology (joint) conditions
*
Yes
No
Please give details
Anaemia (deficiency of red cells/iron deficiency)
*
Yes
No
Please give details
Bleeding/clotting disorders (including history of DVT)
*
Yes
No
Please give details
Diabetes?
*
Yes
No
Please give details
Disability?
*
Yes
No
Please give details
HIV or AIDS?
*
Yes
No
Please give details
Are you currently taking any medication (including the contraceptive pill)?
*
Yes
No
Please give details
Are you taking any drugs that can weaken the immune system? (Hover mouse over text for examples)
*
Yes
No
Please give details
Have you ever had cancer, chemotherapy/radiotherapy/organ transplant?
*
Yes
No
Please give details
Do you have an altered/weakened immune system or condition?
*
Yes
No
Please give details
Mental health issues (including anxiety, depression)?
*
Yes
No
Please give details
Are you pregnant, planning pregnancy or breastfeeding?
*
Yes
No
Not applicable
Please give details
Have you had any live vaccines from another provider in the last four weeks (or are you scheduled to have any)? e.g. MMR, Chickenpox, BCG, Yellow fever, Rotarix
*
Yes
No
Not sure
Please give details
Any other conditions?
*
Yes
No
Please give details
Do you have a first-degree family relative (i.e. a blood relative –mother, father, full brother, sister or child) who has had a serious adverse reaction to a yellow fever vaccine?
*
Yes
No
Please give details
Any additional information
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Consent for a child (less than 16 years) - Please note we cannot administer any vaccines without this consent
If you are over the age of 16 please go straight to the following page
I consent for the above named child to receive vaccinations, medications related to travel and emergency treatment in the event of an allergic reaction to a vaccine. I also confirm that I have parental responsibility.
Yes
No
Signature (print name here)
First Name
Last Name
Full Name
First Name
Last Name
Relationship to child
Father
Mother
Legal Guardian
Other
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Please supply information on any vaccines or malaria tablets taken in the past
You may leave this section blank if you are not aware of your previous vaccine history. Your GP practice is usually happy to give you your list of previous vaccinations. You can then bring it with you to your appointment. If you wish to email the list then you can do so securely to travelklinix@protonmail.com.
Tetanus/polio/diphtheria
Yes
No
Not sure
Date
Typhoid
Yes
No
Not sure
Date
Rabies
Yes
No
Not sure
Date
Yellow fever
Yes
No
Not sure
Date
MMR
Yes
No
Not sure
Date
Hepatitis A
Yes
No
Not sure
Date
Hepatitis B
Yes
No
Not sure
Date
Japanese Encephalitis
Yes
No
Not sure
Date
BCG
Yes
No
Not sure
Date
Influenza
Yes
No
Not sure
Date
Pneumococcal
Yes
No
Not sure
Date
Meningitis ACWY
Yes
No
Not sure
Date
Other
Yes
No
Not sure
Details
Malaria Tablets
Yes
No
Not sure
Details
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Your email will be used to contact you with any vital communications e.g. lab results, clinical issues, urgent notifications
Do you consent for your email to be used for communications regarding information about new services, improvements, research and audit
*
Yes
No
How did you hear about Travel Klinix?
*
Google
Other internet search
Friends/ Family
GP Practice
Poster/ Leaflet
Other
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Consent
I confirm that the information provided above is true to the best of my knowledge and belief. I understand that any omission of important personal medical information can potentially lead to life threatening reactions to any vaccines or medications I (or my child) may receive
*
Yes
No
If you have been referred by your employer, do you consent for your work related vaccine records or test results to be shared with your employer if requested?
Yes
No
Not applicable
Signature (print name here)
*
First Name
Last Name
Full Name
*
First Name
Last Name
If you are having a blood test, medical exam, or potential yellow fever vaccine, please bring your passport with you to your appointment
*
Please click here to confirm you have read the statement above
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