Travel Risk Assessment

  • We like to have 8 weeks notice prior to your trip (longer if complicated itinerary). Please complete this form and call reception a week later.
  • Between 3 & 8 weeks, complete this form and phone 5 working days later to see if a suitable appointment can be found. If an appointment can’t be found please ask reception to print off a list of your vaccines to take to a travel clinic. Appointments will only be fitted in if possible.
  • Less than 3 weeks do not complete this form as you will need to go to a travel clinic for your consultation. Please ask reception to print details of previous vaccines to take with you.

Please complete a separate travel risk assessment for each person travelling who is registered at the practice. We cannot respond to multiple travellers on one form.

Thank you for your co-operation.

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):

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