Travel Risk Assessment

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All questions marked with a * are mandatory

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary.

To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.
We also may need to order the vaccinations that you require.

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Personal Details

Please double check you've entered the correct email address

May be used to identify you

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Dates and Trip Details

Holiday Type: *

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

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Personal Medical History

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?:

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Signed & Dated

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Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Providing NHS Services

Ansdell Medical Centre
Albany Road
Lytham St Annes, Lancashire
FY8 4GW

Telephone: 01253 229520