Travel Risk Assessment

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Personal Details

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 Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

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Gender: *
May be used to identify you
Dates and Trip Details
Holiday Type: *
Type of Trip: *
Accommodation: *
Travelling: *
Staying in area which is: *
Planned Activities: *
Personal Medical History
Including diabetes, heart or lung conditions
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?:
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?:
Have you ever had any of the following vaccinations / malaria tablets?:
Signed & Dated
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This form is automatically dated upon submission.

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Care Quality Commission
Overall Rating: Good

Mayfield Surgery
246 Roehampton Lane
Roehampton
London
SW15 4AA

Telephone: 020 8780 5650