Travel Risk Assessment

Please note that we are not always able to provide appointments for holiday/travel vaccinations at short notice. Therefore, as most vaccinations need to be completed at least six weeks before departure, if you are intending to travel in less than six weeks and we are unable to complete the course of vaccinations in time to guarantee full immunity we may advise you to make arrangements to have your vaccinations at a private travel clinic.

The nearest travel clinic is located at Dolphin House Surgery in Ware, telephone number 07873 876648.

You can also download and print the Travel Risk Assessment form.

Travel Risk Assessment - Hanscombe

If you are human, leave this field blank.

Full Name *

Date of Birth: *

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

Contact Phone Number: *

Email Address: *

Any responses we send will go to this email address.

Sex: *

Male

Female

Indeterminate

Trip Details

Departure Date:

Please use this date format: DD/MM/YYYY

Number of Days Away:

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country/region to be visited, length of stay, and if this is a remote location:

Type of trip:

Business

Pleasure

Other

Holiday type:

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

Other

Please state:

Accommodation:

Hotel

Staying with relatives / family home

Other

Please state:

Travelling:

Alone

With family / friend

In a group

Staying in an area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Other

Please state:

Personal Medical History

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

Please list any current or repeat medications:

Do you have any allergies? (eg. nuts, eggs, antibiotics)

Have you ever had a serious reaction to a vaccine?

Yes

No

Please give details:

Does having an injection make you feel faint?

Yes

No

Do you or any close family members have epilepsy?

Yes

No

Please give details:

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

Yes

No

Please give details:

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Are you pregnant or planning pregnancy or breast feeding?

Have you taken out travel insurance and informed the company of any medical condition you may have?

Yes

No

Have you ever had a Hepatitis A infection?

Yes

No

Please give details:

Please give any further information which may be relevant:

Vaccination History

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

Tetanus

Polio

Diptheria

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? Please also specify if this was ACWY Menc C or Men B. *

Which year did you have the Yellow Fever vaccination? *

Please bring a copy of your original certificate to your appointment.

Which year did you have the Influenza vaccination? *

Which year did you have the Rabies 1 dose vaccination? *

Which year did you have the Rabies 2 dose vaccination?

Which year did you have the Rabies 3 dose vaccination?

Which year did you have the Jap B Enceph dose 1 vaccination? *

Which year did you have the Jap B Enceph dose 2 vaccination?

Which year did you have the Tick Bourne 1 dose vaccination? *

Which year did you have the Tick Bourne 2 dose vaccination?

Which year did you have the Tick Bourne 3 dose vaccination?

Which year did you have the Diptheria vaccination? *

Which year did you have the Typhoid vaccination? Please also specify whether it was oral or injection. *

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

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

For discussion when a travel risk assessment is performed with the practice nurse:

I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

Signed: *

Date:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent