Travel Risk Assessment

If you are travelling abroad please make sure you allow 4 weeks to arrange any vaccinations that may be necessary.

To help the Travel nurses assess your travel needs please submit this form.

Our Travel Administrator will then contact you via email to advise what travel vaccines are recommended and arrange the relevant nurse appointments.

Please note we do not offer travel vaccine appointments at St Faiths surgery only Drayton & Horsford Surgeries.

Travel Risk Assessment

Travel Risk Assessment

Section

Sex:
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:
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):

*