Travel Risk Assessment Form

Please ensure you complete this form 4 to 6 weeks before travel otherwise we are unable to guarantee we can book an appointment with the nurse for any vaccinations required and you may need to go to an independent travel clinic.

Name

Date of birth

Are you:

E mail

Telephone number

Mobile number

Please supply information about your trip in the sections below

Date of departure

Total length of trip

Country 1

Country to be visited

Exact location or region

City or rural

Length of stay

Country 2

Country to be visited

Exact location or region

City or rural

Length of stay

Country 3

Country to be visited

Exact location or region

City or rural

Length of stay

Women only

Are you pregnant?

Details

Are you breast feeding?

Details

Are you planning pregnancy while away?

Details

Previous Vaccines / Malaria Tablets

Please supply information on any vaccines or malaria tablets taken in the past

Tetanus/polio/diphtheria

MMR

Influenza

Typhoid

Hepatitis A

Pneumococcal

Cholera

Hepatitis B

Meningitis

Rabies

Japanese Encephalitis

Tick Borne Encephalitis

Yellow fever

BCG

Malaria Tablets

Other

Any additional information

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This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Newbury Group Practice • Newbury Park Health Centre, 40 Perrymans Farm Road, Newbury Park, IG2 7LE.

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