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.

Please note: this is not an assessment to see if you are fit to travel, the practice nurse is not qualified to make this assessment. If you have other medical concerns of this nature please book an appointment to discuss with the GP in further detail.

Travel Risk Assessment (Advice and Immunisation)

Travel Risk Assessment (Advice and Immunisation)

Please leave at least 4 weeks prior to completing forms to leave sufficient time for vaccines to work and have an appointment at the surgery.
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Permission to leave a voicemail if no answer
Gender:
Are you currently pregnant *
Are you currently breast feeding *
Are you planning a pregnancy near travel *
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
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 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.
*