Travel Risk Assessment Form

Please be aware that we require 6 - 8 weeks' notice before you travel to allow time to review your form and to find a suitable appointment.

If your form is handed in with less than 5 weeks before you travel, you will be asked to attend a travel clinic for your vaccinations which requires payment

Last Updated: 01/06/2023

  • Your Details

    Date of Birth
    For example, 15 3 1984
    Gender

  • Trip Details

    Departure Date
    For example, 15 3 1984

  • Trip Description

    Purpose of Trip
    Type of Trip
    Accommodation
    Travelling
    Location Type
    Activity type

  • Personal Medical History

    Are you taking an immunosuppressant medication
    Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?
    Does having an injection cause you to feel faint?
    Do you or any close family members have epilepsy?
    Do you have any history of mental illness including depression or anxiety?
    Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
    Have you taken out travel insurance?
    If you have a medical condition, have you told your insurance company about it?
    Are you pregnant, planning pregnancy or breast feeding?

  • Vaccination History

    Have you ever had any of the following vaccinations / tablets and if so, when?
    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
    Please ensure you hand this form in to reception between 6 - 8 weeks' before you travel otherwise you will be advised to attend a travel clinic
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