Travel Risk Assessment

 
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All questions marked with a * are mandatory

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary.

  • To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.
  • We also may need to order the vaccinations that you require.
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Personal Details
Please double check you've entered the correct email address
May be used to identify you
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Dates and Trip Details
Holiday Type: *
Type of Trip: *
Accommodation: *
Travelling: *
Staying in area which is: *
Planned Activities: *
  
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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?:
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Signed & Dated
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Privacy Consent

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Providing NHS Services

Contact

Holland House Surgery
Lytham Primary Care Centre
Victoria Street, Lytham
FY8 5DZ

Freckleton Health Centre
Douglas Drive, Freckleton
Lancashire, PR4 1RY

Telephone: 01253 229470

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