Travel Risk Assessment

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All questions marked with a * are mandatory

If you are travelling abroad please make sure you contact us at least 8 weeks in advance 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.
  • We also may need to order the vaccinations that you require.
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Personal Details
Sex:
Please double check you've entered the correct email address
May be used to identify you
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Dates and Trip Details
Have you taken out travel insurance for this trip?: *
Do you plan to travel abroad again in the future?: *
Holiday Type: *
Please select all that apply
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Personal Medical History
Are you fit and well today?: *
Including food, latex, medication
Have you ever had a severe reaction to a vaccine given to you before?: *
Does having an injection make you feel faint?: *
Have you had any surgical operations in the past?: *
Including your spleen or thymus gland removed
Have you recently undergone radiotherapy, chemotherapy or organ transplant?: *
Do you have anaemia?: *
Do you have bleeding/clotting disorders?: *
Including history of DVT
Do you have heart disease?: *
Including angina, high blood pressure
Do you have diabetes?: *
Do you have epilepsy/seizures?: *
Do you have gastrointestinal (stomach) complaints?: *
Do you have liver and/or kidney problems?: *
Do you have HIV/AIDS?: *
Do you have an immune system condition?: *
Do you have any history or mental illness including depression or anxiety?: *
Do you have a respiratory (lung) disease?: *
Do you have a neurological (nervous system) illness?: *
Do you have any rheumatology (joint) conditions?: *
Do you have any spleen problems?: *
Are you or your partner pregnant or planning a pregnancy?: *
Are you breast feeding (if applicable)?: *
Have you or anyone in your family undergone FGM / been cut / circumcised: *
Including prescribed, purchased or a contraceptive pill
Have you ever had any of the following vaccinations / malaria tablets?:
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Appointment

Once you have submitted this form, an appointment will be booked for one of our Practice Nurses to assess your requirements. She will need to talk to you as well at the same time.

Would you prefer a face to face or a telephone consultation for the assessment with our Practice Nurse?: *
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Signed & Dated
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Privacy Consent

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