Travel Risk Assessment

If you require any vaccinations relating to foreign travel you will need to complete a Travel Risk Assessment Form at least 6 weeks before you travel. Upon receipt of your form the nurse will review your requirements and you will be contacted by the surgery to book an appointment. Please note every member of the family will need to complete a travel risk assessment form and you will receive your own individual appointment.

If you have 4 weeks or less before you travel you will not be seen at the surgery, you will need to attend a private travel clinic for vaccinations.

Travel Risk Assessment

Travel Risk Assessment

Sex:
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):

*