Travel Risk Assessment Form

Travel Risk Assessment Form

Grove Medical Practice
To be completed by traveller prior to appointment

You will be contacted to inform you what vaccinations are required and to book an appointment if needed.
Name
Date of Birth

MonthDayYear
Date
Gender
Age
NHS Number
Best contact telephone number
Contact email
Date of departure

MonthDayYear
Date
Total length of trip
Country to be visited (please include all destinations)
Exact location or region (please include for each destination, if more than one)
Length of stay (per destination, if more than one)
City or rural (per destination)
Current health problems/ undergoing treatment
Please list any allergies
Current medication
Have you ever had a serious reaction to a vaccine? If yes, please name the vaccine.
WOMEN ONLY
Are you pregnant? If so, how many weeks
Are you planning a pregnancy?
Are you breastfeeding?
ALL PATIENTS

Please provide details of any vaccines administered in the past not at Grove Medical Practice (please use the bar to scroll through all table options):

	Tetanus/ Polio/ Dipthieria	Typhoid	Cholera	Rabies	Hepatitis A	Hepatitis B	Japanese Encephalitis	MMR	BCG	Influenza	Pneumococcal	Meningitis	Tick Born Encephalitis	Yellow Fever
DATE OF VACCINE

Should be Empty:

Travel Risk Assessment Form

To be completed by traveller prior to appointment

WOMEN ONLY

ALL PATIENTS