Travel Risk Assessment

Please note you will need to complete this form fully. It is essential that one form is filled out per patient travelling, and not to have one form for multiple people. Once completed, our Practice Nurse will review this and call you direct to arrange a mutually convenient time for you to come and have the necessary vaccinations.

Please note this process can take up to 2 weeks and some travel vaccinations need to be given over a course of weeks, so please allow enough time. We do recommend that you submit your form at least 6-8 weeks before your date of travel. This allows the nurse to look through your immunisation history, and to order in any vaccines that may be needed.

Not all travel vaccines are free from the NHS and may incur a charge. If you have been informed that you need a Yellow Fever Vaccination, you will need to pay for this before your appointment. Please also complete the attached form and bring this with you to your appointment

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):

*