Travel Risk Assessment Online Travel Questionaire Please complete the form below to get more information about what travel immunisations you require. If you are travelling abroad, please contact us as early as possible to discuss your vaccinations normally three months before you travel .You will need to complete a travel risk assessment form for each member of your party travelling with you. The nurse will use the information in the form to prepare for your appointment.Once our travel nurses have assessed your form(s) , they will be in contact to arrange an initial telephone consultation to discuss all your travel requirements. They will then arrange for your face to face vaccination appointment or a vaccine course to be commenced. As some vaccinations require more than one injection, please be aware you will need to have follow-up appointments.Details of travel vaccination fees can be found on our website.If we receive the completed form less than 4 weeks prior to travel we will be unable to see patients. This is because: There is insufficient time to plan and arrange appointments Possible insufficient time for the vaccines to be effective Insufficient time for vaccine courses to be completed or the ordering of vaccinations Title * Mr Mrs Miss Ms Other Gender * Female Male Transgender Non-binary/non-conforming Prefer not to respond Full Name * Date of Birth * Address * Address Address Address Postcode Postcode City City Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Email * Contact Number * Destination(s) UK Departure Date * Date of Return * Total duration of trip (in days) * 1st Country being visited (specify areas if long haul) * Length of stay (include stopover destinations) 2nd Country being visited (specify areas if long haul) Length of Stay 3rd Country being visited (specify areas if long haul) Length of Stay Further Information Purpose of your trip * Business Pleasure OtherOther Holiday Type * Package Self organised Backpacking Camping Trekking Cruise Ship OtherOther Accommodation * Hotel With Friends &/or Family OtherOther Travelling with: * Alone With Friends &/or Family Group Setting Urban Rural Altitude OtherOther Planned Activities Safari Adventure OtherOther Personal Medical History Please provide details of your personal medical history and supply details, if necessary Are you fit for travel? * Yes No Any allergies, including food, latex and medication Have you had a severe reaction to a vaccine before * Yes No Any surgical operation in the past, including spleen or thymus gland removed * Yes No Any recent chemotherapy / radiotherapy / organ transplant * Yes No Bleeding / clotting disorders, including a history of DVT * Yes No Heart disease – eg angina, high blood pressure * Yes No Epilepsy /seizures * Yes No Liver or kidney problems * Yes No Immune system condition * Yes No Mental health issues, including anxiety or depression * Yes No Rheumatology (joint) conditions * Yes No Spleen problems * Yes No Any other conditions or issues we should be aware of? Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this? Yes No Don’t Know Women Only Are you or could you be pregnant? Yes No Are you breast feeding? Yes No Are you planning pregnancy while away? Yes No Are you currently taking a n medication (including prescribed, purchased or a contraceptive pill?) Yes No Vaccination history Have you ever had any of the followingvaccinations / malaria tablets, and if so, when? Tetanus * Yes No When Typhoid * Yes No When Meningitis * Yes No When Rabies * Yes No When Malaria tablets * Yes No When Polio * Yes No When Hepatitis A * Yes No When Yellow fever * Yes No When Jap 8 enceph * Yes No When Diphtheria * Yes No When Hepatitis B * Yes No When Influenza * Yes No When Tick borne * Yes No When Other: Declaration * 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 vaccine being given. I confirm that the information provided is accurate to the best of my knowledge. If you are human, leave this field blank. Submit