Travel Risk Assessment

If you are travelling abroad please make sure you complete the below form at least 6 weeks before the date of travel. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Please be aware there is currently a national shortage of travel vaccines and some vaccines may be unavailable from the surgery, however a private travel clinic may be able to offer these vaccines.

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):

*