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

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

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
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):