Travel Assessment Form
Please note: If your date of travel is within the next 8 weeks, we may not have the capacity to provide travel advice and immunisations. Please note: A separate form must be completed for each family member who will be traveling. To find out what travel vaccinations, if any are required, please ring the practice 2 weeks after the completed travel forms have been returned. Last Updated: 02/09/2022
Your Details
Patient Full Name:
*
First Name
Last Name
Patient Date of Birth:
*
-
Day
-
Month
Year
Date
Patient Full Address:
*
Street Address
Street Address Line 2
City
County
Post Code
Patient Email (in-case we need to contact you):
*
example@gmail.com
Dates of Trip
Date of Departure:
*
-
Month
-
Day
Year
Date
Return date or overall length of trip:
*
DD/MM/YYYY or length of trip in Years/Months/Days
Itinerary & Purpose of Visit
Please state the Country and Region you're visiting along with length of stay in each Country and Region:
*
Please tick as appropriate below to best describe your trip
Type of Trip:
*
Please Select
Business
Pleasure
Other
Holiday Type:
*
Package
Camping
Self-Organised
Backpacking
Trekking
Cruise Ship
Other
Accommodation:
*
Hotel
Relatives/Family Home
Other
Travelling:
*
Alone
Family/Friends
Group
Type of area staying in:
*
Urban - town or city
Rural - countryside
Altitude - mountains
Planned Activities:
*
Safari
Adventure
Other
Vaccination History (if known)
Have you ever had any of the following vaccinations/malaria tablets?
*
Tetanus
Typhoid
Meningitis
Rabies
Pneumonia
Polio
Hepatitis A
Yellow Fever
Jap B Encephalitis
Diptheria
Hepatitis B
Influenza
Tick Born
Malaria Tablets
Please verify that you are human:
*
Submit
Should be Empty: