Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Where possible please submit travel forms at least 8 weeks before date of travel, otherwise we can not guarantee there will be time for an assessment to be completed or an appointment available.

Please see our Private Fees for Travel Vaccinations (Updated 01-08-17).

Travel Risk Assessment

Travel Risk Assessment

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Gender:
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):

*

For Official Use

Travel Risk Assessment Performed?

Travel vaccines recommended for this trip

Disease protection

Yes/No

Patient declined vaccine

Vaccine name, dose & schedule for PSD

Hepatitis A

Hepatitis B

Typhoid

Cholera

Tetanus

Diphtheria

Polio

Meningitis ACWY

Yellow Fever

Rabies

Japanese B Encephalitis

Other

Authorisation for Patient Specific Direction (PSD) Use

Travel Advice and leaflets given as per travel protocol
Malaria prevention advice and malaria chemoprophylaxis
(e.g. weight of child)