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
Please use this date format: DD/MM/YYYY.
Gender: *
Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Have you taken out travel insurance for this trip?
Do you plan to travel again in the future?
Type of travel and purpose of trip - please tick all that apply

Please supply details of your personal medical history

Bleeding/clotting disorders (including history of DVT)
Any allergies including food, latex, medication?
Severe reaction to a vaccine previously?
Tendancy to faint with injections?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Recent chemotherapy/radiotherapy/organ transplant?
Any mental health issues (including anxiety, depression)?
Any spleen problems?
Any other conditions?

Women only

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


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

*