Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time 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.

Once you have submitted the form, contact the surgery in 10 working days to be advised by our receptionists of the nurse’s assessment and to book an appointment should any vaccinations be required.

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
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip:
Are you fit and well today?
Any allergies including food, latex, medication?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Please select all that apply:
Have you undergone FGM / been cut / circumcised?
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you ever had any of the following vaccinations / malaria tablets?

Please state which year you had the vaccination(s):

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