Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time (at least 6 – 8 weeks prior to travel) 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. One of these forms needs to be completed for each family member travelling with you (even children/babies).

Once you have completed the forms and submitted contact the practice to arrange an initial telephone appointment with the nurse where they can discuss your requirements and advise what immunisations are recommended. The nurse will then arrange a face to face appointment for you to receive your immunisations.

Please note that there is a charge for some of the vaccinations: Private Fees.

Payment can be made by cash or cheque.

Further Travel Information

The following websites will give you additional travel advice:

• Travel Health for information of vaccinations available on NHS
• MASTA for Private Vaccination Clinics
• GOV.UK for specific country travel advice
• EHIC to apply for your free European Health Insurance Card

Travel Risk Assessment

Travel Risk Assessment

Full Name *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Responses we send will go to this email address

Gender:

Male

Female

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country to be visited, length of stay, and how remote you'll be from medical help:

Type of trip:

Business

Pleasure

Other

Holiday type:

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

Accommodation:

Hotel

Relatives / family home

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Other

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)

List any current or repeat medications

Do you have any allergies for example to eggs, antibiotics, nuts?

Have you ever had a serious reaction to a vaccine given to you before?

Yes

No

Don't Know

Does having an injection make you feel faint?

Yes

No

Don't Know

Do you or any close family members have epilepsy?

Yes

No

Don't Know

Do you have any history or mental illness including depression or anxiety?

Yes

No

Don't Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Don't Know

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Yes

No

Don't Know

Are you pregnant or planning pregnancy or breast feeding?

Please write below any further information which may be relevant:

Have you ever had any of the following vaccinations / malaria tablets?

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Other / Malaria tablets

Which year did you have the Tetanus vaccination? *

Which year did you have the Polio vaccination? *

Which year did you have the Hepatitis A vaccination? *

Which year did you have the Hepatitis B vaccination? *

Which year did you have the Meningitis vaccination? *

Which year did you have the Yellow Fever vaccination? *

Which year did you have the Influenza vaccination? *

Which year did you have the Rabies vaccination? *

Which year did you have the Jap B Enceph vaccination? *

Which year did you have the Tick Bourne vaccination? *

Which year did you have the Diptheria vaccination? *

Which year did you have the Typhoid vaccination? *

If 'Other / Malaria tablets' please list here: *

Which year did you have the other vaccination / malaria tablets? *

Signed: *

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

Date:

If you are human, leave this field blank.