Please complete the form below and then arrange for two consecutive appointments (i.e. two appointments together) with one of our practice nurses; you can book your appointments on the next page after submitting your form. We recommend that this is done at least 8 weeks before you leave for your holiday. Our Travel Advice page is filled with useful information if you are planning to travel outside of the UK.  For registered patients only.

Travel risk assessment form

Select Your Practice * Parkway Health Centre - CR0 0JA Fieldway Medical Centre - CR0 9EU Headley Drive Surgery - CR0 0QL

Name *

Gender *

Male

Female

Email Address *

Date of birth *

Please use this date format: DD/MM/YYYY

Date of departure *

Return date *

Please give details of country to be visited, length of stay, and how remote you'll be from medical help *

Type of trip *

Business

Pleasure

Other

Holiday type *

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

Accommodation *

Hotel

Relatives / family home

Other

Travelling *

Alone

With family / friend

In a group

Staying in area which is *

Urban

Rural

Altitude

Planned activities *

Safari

Adventure

Other

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions) *

List any current or repeat medications

Do you have any allergies for example to eggs, antibiotics, nuts? *

Have you ever had a serious reaction to a vaccine given to you before? *

Don't Know

No

Yes

Does having an injection make you feel faint? *

Don't Know

No

Yes

Do you or any close family members have epilepsy? *

Don't Know

No

Yes

Do you have any history or mental illness including depression or anxiety? *

Don't Know

No

Yes

Have you recently undergone radiotherapy, chemotherapy or steroid treatment? *

Don't Know

No

Yes

Women only: Are you pregnant or planning pregnancy or breast feeding?

Don't Know

No

Yes

Have you taken out travel insurance and if you have a medical condition, have you informed the insurance company about this? *

Don't Know

No

Yes

Please write below any further information which may be relevant

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

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Other / Malaria tablets

Which year did you have the Tetanus vaccination?

Which year did you have the Polio vaccination?

Which year did you have the Hepatitis A vaccination?

Which year did you have the Hepatitis B vaccination?

Which year did you have the Meningitis vaccination?

Which year did you have the Yellow Fever vaccination?

Which year did you have the Influenza vaccination?

Which year did you have the Rabies vaccination?

Which year did you have the Jap B Enceph vaccination?

Which year did you have the Tick Bourne vaccination?

Which year did you have the Diptheria vaccination?

Which year did you have the Typhoid vaccination?

If 'Other / Malaria tablets' please list here: *

Which year did you have the other vaccination / malaria tablets?

Signed *

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given. I confirm that I have read and understood the Travel Advice.

Date *

Please use this date format: DD/MM/YYYY

If you are human, leave this field blank.