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)

If you are human, leave this field blank.

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.

Full Name *

Date of Birth: *

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

Preferred Phone Number:

Alternative Phone Number

Email Address: *

Any responses we send will go to this email address.

Permission to leave a voicemail if no answer

Yes

No

Gender:

Male

Female

Are you currently pregnant *

Yes

No

Are you currently breast feeding *

Yes

No

Are you planning a pregnancy near travel *

Yes

No

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 and and area you will be visiting. *

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

Pilgrimage

Other

Please state:

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

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

Please write below any further information which may be relevant:

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

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Tetanus

Other / 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:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent - it may take up to 5 working days before I receive a reply.