Travel Risk Assessment

If you are travelling abroad please complete the following form with plenty of time to arrange any vaccinations that may be necessary.

Please do not submit this form if you are travelling in less than 8 weeks. If you submit this form with a departure date of less than 8 weeks this will be rejected and returned and you will be advised to contact your local travel clinic.

To help the travel nurse assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Immunisation Shortages

We have just been informed that there is a national shortage of both the Viatim and Typhoid vaccinations, which is beyond our control and we currently have no stock of these.

You may find that other vaccination clinics still have these in stock for you, but there would also be a charge from them, for this.

You are of course welcome to keep checking back with us, as we might have stock in at some point.

Travel Risk Assessment

Travel Risk Assessment

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Including diabetes, heart or lung conditions
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Have you ever had any of the following vaccinations / malaria tablets?

Please state which year you had the vaccination(s):

*