Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Travel Risk Assessment

Travel Risk Assessment

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Please note that your email address will be saved as part of your contact details in your medical records. We may contact you via your email address if you become locked out of your online account and need your password sent, or to send you health questionnaires.

In future we may send you clinical letters via email instead of as a posted letter for speed and to reduce our carbon footprint. You can opt-out of this by telling the Practice.

Gender:
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Including diabetes, heart or lung conditions
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Have you ever had any of the following vaccinations / malaria tablets?

Please state which year you had the vaccination(s):

*