Travel Risk Assessment

If you are travelling abroad please make sure you contact us and book a travel vaccination appointment preferably 6 weeks but no less than 4 weeks before your date of departure.

Booking your appointment and submitting this form in good time is to help the Nurse assess your travel needs and order any vaccination medications that we do not routinely hold in practice.

It is important that we are in receipt of the assessment form in good time before your appointment, if you are under 4 weeks away from a trip please contact a travel vaccination clinic not your GP.

Travel Risk Assessment

Travel Risk Assessment

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

*