Travel risk assessment

Section

Your country of origin:

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:

What modes of transport will you be using?

Do you plan to travel abroad again in the future?

Have you taken out travel insurance for this trip?

Holiday type:

Type of trip:

Accommodation:

Hotel

Hostel

Relatives / family home

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Diving

Other

Additional information:

Medical History

List any recent or past medical history of note:

Including diabetes, heart or lung conditions

Do you have any allergies, including food, eggs, nuts, latex, or medication?

Yes

No

Don’t Know

Please specify:

Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?

Yes

No

Don’t Know

Please specify:

Do you have a tendency to faint when receiving injections?

Yes

No

Don’t Know

Please specify:

Any surgical operations in the past, including e.g. open-heart surgery, spleen or thymus gland removal?

Yes

No

Don’t Know

Please specify:

Have you recently undergone chemotherapy, radiotherapy, or an organ transplant?

Yes

No

Don’t Know

Please specify:

Do you have anemia?

Yes

No

Don’t Know

Please specify:

Do you have a bleeding or clotting disorder, including a history of deep vein thrombosis (DVT)?

Yes

No

Don’t Know

Please specify:

Do you have heart disease, such as angina or high blood pressure?

Yes

No

Don’t Know

Please specify:

Do you have diabetes?

Yes

No

Don’t Know

Please specify:

Do you have any additional needs or a disability?

Yes

No

Don’t Know

Please specify:

Do you have epilepsy or seizures, or does a close family member have a history of seizures?

Yes

No

Don’t Know

Please specify:

Do you have any gastrointestinal (stomach) complaints?

Yes

No

Don’t Know

Please specify:

Do you have any liver or kidney problems?

Yes

No

Don’t Know

Please specify:

Do you have HIV or AIDS?

Yes

No

Don’t Know

Please specify:

Do you have an immune system condition, such as blood cancer?

Yes

No

Don’t Know

Please specify:

Do you have any mental health conditions, including anxiety or depression?

Yes

No

Don’t Know

Please specify:

Do you have a neurological (nervous system) condition?

Yes

No

Don’t Know

Please specify:

Do you have a respiratory (lung) disease, such as asthma or COPD?

Yes

No

Don’t Know

Please specify:

Do you have a rheumatology (joint) condition?

Yes

No

Don’t Know

Please specify:

Do you have problems with your spleen?

Yes

No

Don’t Know

Please specify:

Do you have any other medical conditions not listed above?

Yes

No

Don’t Know

Please specify:

Are you or your partner currently pregnant or planning a pregnancy?

Yes

No

Don’t Know

Please specify:

Are you currently breastfeeding (if applicable)?

Yes

No

Don’t Know

Please specify:

Have you or anyone in your family undergone FGM, been cut, or been circumcised?

Yes

No

Don’t Know

Please specify:

List any current or repeat medications:

Including prescribed, purchased or a contraceptive pill

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

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

Tetanus:

Polio:

Hepatitis A:

Hepatitis B:

Meningitis:

MMR:

Pneumococcal:

Cholera:

BCG:

Yellow Fever:

Influenza:

Rabies:

Jap B Enceph:

Tick-borne Enceph (TBE):

Diptheria:

Typhoid:

Please state the dates you had the Covid-19 vaccination(s) and brand information:

Covid-19:

Other / Malaria tablets please list here:

Please write below any further information which may be relevant:

Vaccines

Name of the private travel clinic provider:

Date of consultation:

Travel vaccines recommended and administered by the Private Travel Clinic:

For example, diseases protected against, vaccine name, dose, schedule and if you declined any vaccines

NHS-funded travel vaccines recommended by the Private Travel Clinic can be administered by the Practice Nurse at the surgery:

Please indicate if you were recommended any of the following vaccines. Add the vaccine name, dose, schedule or if you declined the recommendation to have the vaccine.

Hepatitis A:

Typhoid:

Tetanus/Polio/Diphtheria:

Cholera:

You will need to provide the evidence of consultation and vaccine recommendations from the private clinic. These can be uploaded, emailed or left at the surgery reception after submitting the form. The practice nurses will not accept and process any request without the evidence.

Upload a photograph or document

Maximum upload size: 67.11MB

For more information on travel health and vaccinations, visit our General Travel Advice page or NaTHNaC.

This form collects your name, date of birth, email, other personal information, and medical details. This information is used to confirm your registration with the practice, to allow the practice team to contact you, and to update your medical records held by the practice and our NHS partners. Please read our Privacy Policy to understand how we protect and manage your submitted data.

Patient’s consent

I consent to the practice collecting and storing my data provided in this form. I give my consent to be vaccinated today. I understand and have read all the information provided in this form and other travel websites. I understand the risks associated with my travel.

Signature of the patient (or representative if under 16):

Date:

Terms and conditions

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 2 working days before I receive a reply.

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Section

Medical History

Vaccines