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Travel risk assessment

Travel Vaccinations

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:

Medical History

Including diabetes, heart or lung conditions
Do you have any allergies, including food, eggs, nuts, latex, or medication?
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?
Do you have a tendency to faint when receiving injections?
Any surgical operations in the past, including e.g. open-heart surgery, spleen or thymus gland removal?
Have you recently undergone chemotherapy, radiotherapy, or an organ transplant?
Do you have a bleeding or clotting disorder, including a history of deep vein thrombosis (DVT)?
Do you have any additional needs or a disability?
Do you have HIV or AIDS?
Are you or your partner currently pregnant or planning a pregnancy?
Are you currently breastfeeding (if applicable)?
Including prescribed, purchased or a contraceptive pill
Have you ever had any of the following vaccinations / malaria tablets?

Typhoid fever

Hepatitis A

Hepatitis B

Cholera

Yellow Fever

Influenza

Rabies

Japanese Encephalitis

Other

Was this anti-malarial medication?

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.

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
Terms and conditions