Travel Risk Assessment

If you are travelling abroad, please complete and submit this form ideally 8 weeks prior to travel.

Although we will do our best to provide you with travel health advice, it may not be possible to complete vaccination schedules if your form is received outside of this time period.

Please note, one travel form should be completed for each person travelling.

Travel Risk Assessment

Do you give consent to receiving text messages from the Practice? *
Sex:

Women Only

Are you pregnant or planning pregnancy? *
Are you breastfeeding? *
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Have you taken out travel insurance? *
If you have a medical condition, have you informed the insurance company about this? *

Itinerary and Purpose of Visit

(In order of itinerary)
Is the location remote from medical help? *
(In order of itinerary)
Is the location remote from medical help?
(In order of itinerary)
Is the location remote from medical help?
(In order of itinerary)
Is the location remote from medical help?
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?
If you have a medical condition, have you informed your insurance company about this? *
Have you ever had any of the following vaccinations / malaria tablets?

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

*