Travel risk assessment

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

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 to be visited, length of stay, and how remote you’ll be from medical help:

Type of trip:

Business

Pleasure

Other

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

Other

List any recent or past medical history of note:

Including diabetes, heart or lung conditions

List any current or repeat medications:

List any allergies:

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

Do you or any close family members have epilepsy?

Yes

No

Don’t Know

Do you have any history or mental illness including depression or anxiety?

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

Are you pregnant or planning pregnancy or breast feeding?

Please write below any further information which may be relevant:

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

Tetanus: Required

Polio: Required

Hepatitis A: Required

Hepatitis B: Required

Meningitis: Required

Yellow Fever: Required

Influenza: Required

Rabies: Required

Jap B Enceph: Required

Tick-borne Enceph (TBE): Required

Diptheria: Required

Typhoid: Required

Other / Malaria tablets please list here: Required

Signed: Required

Date:

Terms and Conditions: Required

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.

I confirm that this problem is not an emergency. I understand that the practice will not deal with this problem while the practice is closed.

If the problem worsens and may require immediate help, I will visit NHS 111 Online or call 111. In an emergency, I will call 999.

Tell us whether you accept cookies

Temporary Suspension