Travel Risk Assessment

Travel Vaccinations

Linden Medical group is not a specialist travel centre, however, some of our Practice Nurses have completed the relevant training to deliver NHS travel vaccinations and general travel advice.

Please complete this form 8 – 10 weeks prior to travel and return it to the Linden Avenue site. Please complete a separate form for each traveller (including children). One of our Practice Nurses will contact you to advise on the appropriate course of treatment if required.

If you are aware you require a non-NHS travel vaccination e.g. yellow fever vaccine, please contact a travel centre as private travel vaccinations are not available at Linden Medical Group.

A summary of vaccinations held on your records can be obtained from reception.

The following websites would be useful to look at prior to travel:

www.travelhealthpro.org.uk

www.nhs.uk/conditions/travel-vaccinations

www.fitfortravel.nhs.uk

Travel Risk Assessment

Please supply information about your trip in the sections below

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?

Type of travel and purpose of trip

Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:

Please supply details of your personal medical history

Are you currently fit and well?
Any allergies including food, latex, medication?
Severe reaction to a previous vaccine?
Tendency to faint with injections?
Any surgical operations in the past, e.g. your spleen or thymus gland removed?
Recent chemotherapy / radiotherapy / organ transplant?
Any anaemia?
Any bleeding/clotting disorders (including history of DVT)?
Any heart disease (e.g. angina, high blood pressure)?
Any diabetes?
Any disabilities?
Any epilepsy or seizures?
Any gastrointestinal (stomach) complaints?
Any Liver and/or kidney problems?
Any HIV/AIDS?
Any immune system conditions?
Any mental health issues (including anxiety, depression)?
Any neurological (nervous system) illness?
Any respiratory (lung) disease?
Any rheumatology (joint) conditions?
Any spleen problems?

Women Only

Are you pregnant?
Are you breast feeding?
Are you planning pregnancy whilst away?
Have you undergone FGM/been cut?

Please supply information on any vaccines or malaria tablets taken in the past

Have you ever had any of the following vaccinations / malaria tablets?

Please state which year you had the vaccination(s):

*