Travel Health

Please complete the form below. Once completed you will need to book two consecutive appointments (i.e. two appointments together) with one of our practice nurses.

We recommend that you attended your appointments 8 weeks before you leave for your holiday.

Full Name

First Last

Date of Birth

Sex at Birth

Gender

Please Specify

Enter Email Confirm Email

Contact Number

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

Select all applicable

Please Specify

Holiday type

Package

Self organised

Backpacking

Camping

Trekking

Cruise Ship

Other

Select all applicable

Please Specify

Accommodation

Hotel

Relatives / Family Home

Other

Please Specify

Travelling

Alone

With family / friend

In a group

Select all applicable

Staying in area which is…

Urban

Rural

Altitude

Select all applicable

Do you have any recent or past medical history of note?

Including diabetes, heart or lung conditions

List any current or repeat medications

Example: Glucovance

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?

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?

Are you pregnant or planning pregnancy or breast feeding?

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

Please enter below any further information which may be relevant Optional

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

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 Diphtheria vaccination?

Which year did you have the Typhoid vaccination?

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

Patient Signature

(PRINT your full name)

Name Optional

This field is for validation purposes and should be left unchanged.

Travel Vaccinations

Travel Risk Assessment Form