Travel Risk Assessment Form

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Information

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment. Please be aware that you should be vaccinated at least 6 weeks before you travel. Kindly also allow up to 2 weeks for the practice to process your assessment for your vaccinations. There is a fee of £10 for a private consultation for travel assessment per patient. We only offer the following vaccines for FREE through the NHS:
• Hep A
• Polio
• Typhoid
• Cholera
All other travel advice and vaccines will be a private travel clinic assessment and will attract a fee of £20 per vaccine.

Personal Details

Please double check you've entered the correct email address

Gender: *

Dates and Trip Details

Please give details of country to be visited, destination(s) within the country, length of stay, and mode of transport:

Destination Description – Indicate all that apply: *

Purpose of Trip – Indicate all that apply: *

Accommodation – Indicate all that may apply: *

Do you have travel health insurance (covering pre-existing health conditions and planned activities if relevant)?: *

Personal Medical History

Please tick either yes or no. If you answer yes to any of the questions, please provide details below.

Are you well today?:

Do you have any health conditions? E.g. diabetes, respiratory (breathing) problems, heart disease, neurological illness, liver or kidney problems, blood disorders [e.g. sickle cell disease, clotting or bleeding issues]:

Do you have any allergies? E.g. food, medication or latex:

Have you, or a first degree relative (parents, brother, sister, or child), ever experienced any mental health issues, even mild anxiety, or depression?:

Do you have, or have you had, a condition that could impair your immune system? E.g. HIV / AIDS, blood cancer:

In the last 12 months, have you taken any medication or had treatment that could impair your immune system? E.g. chemotherapy, radiotherapy, high dose steroids:

Have you ever had any surgery? E.g. open-heart surgery, transplant surgery, spleen or thymus gland removal:

Are you receiving regular treatment or follow up with your GP / hospital specialist?:

Do you have any disability or mobility problems?:

Do you, or a first degree relative (parents, brother, sister or child), have epilepsy or seizures?:

Have you, or anyone in your family, ever had a severe reaction to a vaccine or malaria medication?:

Are you or your partner pregnant or planning a pregnancy?:

Are you breast feeding? (if applicable):

If you answered yes to any of the questions above, please provide details here with any other important information regarding your health, including problems experienced with previous travel.

Please give details of any medication you are taking, including prescribed / self-treatment / over-the-counter remedies and contraception.

Vaccine History

If you have received vaccinations elsewhere which will not be in our clinic records, please provide details here.

BCG

Cholera

COVID-19

Diphtheria / Tetanus / Polio

Hepatitis A

Hepatitis A / B

Hepatitis A / Typhoid

Hepatitis B

Japanese encephalitis

Influenza

Meningitis ACWY

MMR

Rabies

Tick-borne encephalitis

Typhoid

Yellow fever

Other

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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CONTACT DETAILS

Broom Road Medical Practice
23 Broom Road
Shirley
Croydon
Surrey
CR0 8NG

Telephone: 020 8777 5511
Out-Of-Hours: 111

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