Travel Risk Assessment

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Are you travelling in less than 8 weeks?: *

As you are travelling in less than 8 weeks, you are advised to attend a Travel Clinic.

Please access National Travel Health Network and Centre (NaTHNaC) for travel health information.

You are unable to continue using this contact form: *

Please proceed to the next page to complete the form.

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Personal Details

Please double check you've entered the correct email address

Gender: *

May be used to identify you

Dates and Trip Details

Holiday Type: *

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

Personal Medical History

Including diabetes, heart or lung conditions

Have you ever had any of the following:: *

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

Does having an injection make you feel feint?:

Do you plan to travel abroad again in the future?:

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?:

Women Only

Are you pregnant?:

Are you breast feeding?:

Are you planning on pregnancy while away?:

Signed & Dated

Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Travel Risk Assessment

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THE BARN SURGERY

PEACEMARSH SURGERY

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