Travel Questionnaire

Please complete and submit the Travel Risk Assessment Form below and make an appointment with the practice nurse at least eight weeks before you are due to travel for advice on vaccines. Patients are advised that consultation will be face to face only, ie. the practice nurse will not engage in a telephone or email conversation.
There is a charge for some vaccines and vaccination certificates. Further information is available on the dedicated travel page on our website.

Personal details
Trip dates
Itinerary

* Availability of medical help: If you will be travelling to a place where medical help is not readily on hand, estimate how long it would take to reach a doctor.

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Trip description (please tick all appropriate boxes)

Purpose of trip:

Type of trip:

Accommodation:

Travelling:

Location type:

Activity type:

Personal medical history
Vaccination history

Have you ever had any of the following vaccinations / tablets and if so, when?