Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time (at least 2 weeks before your departure) 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.

The Travel Nurses will check your form and if you do not need to make an appointment they will contact you to let you know.

Travel Risk Assessment

Travel Risk Assessment

Please use this date format: DD/MM/YYYY.
Please state type of number:
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
For multi destination or complex travel please provide a copy of your itinerary to the Practice. It is advisable for these types of trips that you attend an appointment 6-8 weeks prior to travel.
Holiday type:
Type of trip:
Accommodation: *
Travelling:
Staying in area which is:
Planned activities:
Including diabetes, heart or lung conditions
Are you allergic to eggs?
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?
Are you currently taking any disease suppressing medicines?
Have you had your spleen removed?
Do you suffer from any of the following (please select all that apply):
Do you take an oral contraceptive pill?
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):

*
*