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 AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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