Travel Risk Assessment

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Personal Details

If you are travelling abroad please make sure you complete the form at least 12 weeks before travel so we can arrange any vaccinations that may be necessary. Please complete one form per person travelling, including children so we can work out each person's individual plan and save the information to their medical records.

Please double check you've entered the correct email address

Gender: *

May be used to identify you

Dates and Trip Details

Holiday Type: *

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

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?:

Signed & Dated

Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. 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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Contact Details

Moatfield Surgery
St Michael's Road
East Grinstead
West Sussex
RH19 3GW

Telephone: 01342 327 555
Email:
sxicb-wsx.moatfield.surgery@nhs.net

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