Travel Risk Assessment

If you are travelling abroad, you are requested to research the country being visited, including all countries visited if cruising, by accessing the following website:

www.fitfortravel.nhs.uk/destinations

Please complete the Travel Risk Assessment form below and return to the surgery at least 6 weeks before travelling to enable the vaccination course to be administered in time.

For any vaccinations which are not available on the NHS, patients are asked to seek advice via an independent travel clinic.

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):

*