Travel Risk Assessment

We offer a Travel Consultation Service for our patients, but appointments can only be assured a minimum of six weeks before departure.

A form should be submitted online or can be collected from reception ONLY when an appointment has been made, and a minimum of a week before the date you are to be seen.

Please note, we do not offer the following travel vaccines: Rabies, Japanese Enchephalitis, Tick-bourne encephalitis, Hepatitis B, Meningitis ACWY or Yellow Fever – should you require any of these vaccines you would need to attend a Private Travel Clinic or Chemist.

Travel Risk Assessment

If you are human, leave this field blank.

Full Name *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Your country of origin *

Gender: *

Male

Female

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Date of Departure: *

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country to be visited, exact location or region, city or rural and length of stay:

Have you taken out travel insurance for this trip?

Yes

No

Do you plan to travel again in the future?

Yes

No

Type of travel and purpose of trip - please tick all that apply

Holiday

Staying in hotel

Backpacking

Business trip

Cruise ship trip

Camping/hostels

Expatriate

Safari

Adventure

Volunteer work

Pilgrimage

Diving

Healthcare worker

Medical tourism

Visiting friends/family

Please supply details of your personal medical history

Bleeding/clotting disorders (including history of DVT)

Yes

No

Don't Know

Any allergies including food, latex, medication?

Yes

No

Don't Know

Severe reaction to a vaccine previously?

Yes

No

Don't Know

Tendancy to faint with injections?

Yes

No

Don't Know

Any surgical operations in the past, including e.g. your spleen or thymus gland removed?

Yes

No

Don't Know

Recent chemotherapy/radiotherapy/organ transplant?

Yes

No

Don't Know

Any mental health issues (including anxiety, depression)?

Yes

No

Don't Know

Any spleen problems?

Yes

No

Don't Know

Any other conditions?

Yes

No

Don't Know

Please write below any details which may be relevant:

Women only

Are you pregnant, planning pregnancy or breast feeding?

Have you undergone FGM/been cut/circumcised?

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

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

Tetanus

Polio

Diptheria

MMR (mumps, measles, rubella):

Influenza

Typhoid

Hepatitis A

Hepatitis B

Pneumococcal

Cholera

Meningitis

Rabies

Jap B Enceph

Tick-borne Enceph (TBE):

Yellow fever

BCG tuberculosis (TB) vaccine

Malaria tablets

Other

Please state which year you had the vaccination(s):

Tetanus: *

Polio: *

Diptheria: *

Hepatitis A: *

Hepatitis B: *

Pneumococcal: *

Cholera: *

Meningitis: *

Yellow Fever: *

Influenza: *

Rabies: *

MMR (mumps, measles, rubella/German measles): *

Jap B Enceph: *

Tick-borne Enceph (TBE): *

BCG tuberculosis (TB) vaccine: *

Typhoid: *

Other: *

Malaria tablets please list here: *

Any additional information:

Signed: *

Date:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent - it may take up to 2 working days before I receive a reply.