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, this would normally be at least 6-8 weeks prior to travel. To help the nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment can be made.

Please complete and submit the form and the nurses will review the information provided and get in touch. Please do not make an appointment before this has happened.

Please note, you must complete a form for each member of the household that is due to travel.

Please also note that some travel vaccines do incur a fee and this will be detailed to you when the review has taken place.

Further information for patients and details of the charges are shown in the attached document: Wallington Family Practice travel vaccine costs

Travel Risk Assessment

Travel Risk Assessment

If you are human, leave this field blank.

Please note that the Practice will attempt to accommodate your request, but cannot guarantee an appointment before your date of travel.

Full Name *

Date of Birth: *

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

Phone Number: *

Email Address: *

Any responses we send will go to this email address.

Gender:

Male

Female

Indeterminate

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:

Holiday type:

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

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:

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

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick-borne Enceph (TBE):

Other / Malaria tablets

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

Tetanus: *

Polio: *

Hepatitis A: *

Hepatitis B: *

Meningitis: *

Yellow Fever: *

Influenza: *

Rabies: *

Jap B Enceph: *

Tick-borne Enceph (TBE): *

Diptheria: *

Typhoid: *

Other / Malaria tablets please list here: *

Signed: *

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.