PHC Travel Risk Assessment Form

  • PHC Travel Risk Assessment Form

    We are almost there. This is your safety side of the planning. Provide any important information to help us assess your travel needs safely and effectively.

  • Traveller Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is the person completing this form the traveller?*

  • Support Requested

  • What support would you like from a PHC companion? (Select all that apply)*
  • What would you most value from a travel companion?

  • Health Overview

  • Do you have any diagnosed medical conditions?*
  • Do you currently receive any of the following?*
  • Do you have any of the following medical conditions?
  • Have you been admitted to hospital in the past 6 months?

  • Fitness to Travel

  • Has your doctor confirmed you are fit to travel?*
  • PHC may request medical clearance before travel if required.
  • Have you travelled by air in the last 12 months?*

  • Mobility Assessment

  • Can you walk independently through an airport?*
  • Can you use stairs?*
  • Can you sit comfortably for long periods?*
  • Do you use any mobility aids?*
  • Will airport wheelchair assistance be required?
  • Do you believe one companion will be sufficient for this trip?

  • Falls Risk

  • Have you fallen in the last 12 months?*
  • Do you feel unsteady when walking?*

  • Memory and Cognitive Support

  • Do you experience any of the following?*
  • Do you become fatigued easily when walking long distances?

  • Medication

  • Do you take medication regularly?*
  • Will medication need to be taken during travel?*
  • Will you require assistance managing medication?*
  • Do you have any allergies we should be aware of?
  • Is your medication time-sensitive (e.g., insulin, Parkinson's medication)?

  • Behavioural or Anxiety Considerations

  • Do any of the following apply?*
  • Have you ever become lost or wandered away in unfamiliar environments?

  • Personal Care Support

  • Do you require assistance with any of the following?*
  • Do you use continence products (pads, catheter, etc.)?

  • Travel Insurance

  • Do you have travel insurance?*
  • PHC requires clients to hold appropriate travel insurance for the duration of the trip.

  • Travel Expenses

  • Travel companions require expenses to be covered. This usually includes, but is not limited to: Flights, Accommodation, Meals, Transport,Time. Do you accept to covering these costs?*

  • Safety Screening

  • Do any of the following apply?*

  • Additional Support Needs

  • Consent

  • Should be Empty: