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We use secure, NHS approved software to provide video consultations
safely and effectively for our patients.

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Hickings Lane Medical Centre

Hickings Lane Medical Centre

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Hickings Lane Medical Centre

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Travel Risk Assessment Form

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Travel Risk Assessment Form

Travel Risk Assessment Form

Get advice about travelling abroad, including the latest on safety, security and travel warnings: Find out more.

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.

Travel risk assessment form

Select your practice *

Full name *

Date of birth *

Sex at Birth *

Please select your sex as recorded at birth.

Gender *

Please select the gender that you most identify with.

Other (Please specify)

Email address *

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 (Select all applicable) *

Business

Pleasure

Other

Other (Please specify)

Holiday type (Select all applicable) *

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

Accommodation (Select all applicable) *

Hotel

Relatives / family home

Other

Other (Please specify)

Travelling (Select all applicable) *

Alone

With family / friend

In a group

Staying in area which is... (Select all applicable) *

Urban

Rural

Altitude

Planned activities (Select all applicable) *

Safari

Adventure

Other

Other (Please specify)

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions) *

List any current or repeat medications

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? *

Yes

No

Don't know

Does having an injection make you feel faint? *

Yes

No

Don't know

Do you or any close family members have epilepsy? *

Yes

No

Don't know

Do you have any history or mental illness including depression or anxiety? *

Yes

No

Don't know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment? *

Yes

No

Don't know

Women only: Are you pregnant or planning pregnancy or breast feeding?

Yes

No

Don't know

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

Yes

No

Don't know

Please write below any further information which may be relevant

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

Tetanus

Polio

Diphtheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Other / Malaria tablets

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?

If 'Other / Malaria tablets' please list here: *

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

Patient Signature *

Text

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If you are human, leave this field blank.

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