Travel Risk Assessment

Our Nurse can provide comprehensive travel health advice and arrange for appropriate immunisations. Please fill in this form for every person travelling at least 8 weeks before departure if possible. Vaccines need time to take effect and some may require a course over several weeks.

This service is only for patients registered at Hilltops Medical Centre.

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):

*