Travel risk assessment

Please leave at least 4 weeks prior to completing forms to leave sufficient time for vaccines to work and have an appointment at the surgery.

Section

Permission to leave a voicemail if no answer

Yes

No

Are you currently pregnant

Yes

No

Are you currently breast feeding

Yes

No

Are you planning a pregnancy near travel

Yes

No

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 and and area you will be visiting.

Holiday type:

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

Pilgrimage

Other

Please state:

Do you have any allergies for example to eggs, antibiotics, nuts?

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

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

Please write below any further information which may be relevant:

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

Signed:

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

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.

Tell us whether you accept cookies

Section