Travel Risk Assessment

This form should be completed and returned to the Practice at least 8 weeks prior to your departure date.
A separate form is required for each person travelling.
Should you require any vaccinations, each person travelling will need a separate appointment. If you fail to attend your appointment, we will not be able to offer you another one.
A member of the Practice team will contact you once your form has been reviewed – please ensure that we have an up-to-date contact telephone number (preferably a mobile number).

Name

Address

Date of Birth

Gender

Email Address

Telephone Number

Mobile Number

Please supply information about your trip in the sections below

Date of Departure

Total length of trip

Country to be visited

Exact location or region

City or Rural

Length of stay

Country to be visited

Exact location or region

City or Rural

Length of stay

Country to be visited

Exact location or region

City or Rural

Length of stay

What modes of transport will you be using?

Have you taken out travel insurance for this trip?

Do you plan to travel abroad again in the future?

Please supply details of your personal medical history

Are you fit and well today

Details

Any allergies including food, latex, medication

Details

Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?

Details

Tendency to faint with injections

Details

Any surgical operations in the past, including e.g. open-heart surgery, spleen or thymus gland removal?

Details

Recent chemotherapy/radiotherapy/organ transplant

Details

Anaemia

Details

Bleeding /clotting disorders (including history of DVT)

Details

Heart disease (e.g. angina, high blood pressure)

Details

Diabetes

Details

Additional needs and/or disability

Details

Epilepsy/seizures (or in a first degree relative?)

Details

Gastrointestinal (stomach) complaints

Details

Liver and or kidney problems

Details

HIV/AIDS

Details

Immune system condition e.g. blood cancer

Details

Mental health issues (including anxiety, depression)

Details

Neurological (nervous system) illness

Details

Respiratory (lung) disease

Details

Rheumatology (joint) conditions

Details

Spleen problems

Details

Any other conditions?

Details

Are you or your partner pregnant or planning a pregnancy?

Details

Are you breast feeding (if applicable)

Details

Please list any medication you are currently taking (including prescribed or purchased)

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

Tetanus/polio/diphtheria

Typhoid

Cholera

Rabies

Yellow fever

MMR

Hepatitis A

Hepatitis B

Japanese encephalitis

BCG

Influenza

Pneumococcal

Meningitis

Tick borne encephalitis

Other

COVID-19 (Dates, brand etc)

Malaria Tablets

Any additional information:

Information about Travel Clinics if non-NHS vaccinations or Malaria treatment are required or if required in less than 8 weeks

The following vaccines are free of charge under the NHS:

Hepatitis A

Typhoid

Diphtheria & Polio (combined)

Cholera

All other travel vaccinations and Malaria treatment would require contacting one of the local private travel clinics.

These are the providers we are aware that offer travel vaccinations, but the list is not exhaustive and please contact your local pharmacy to find out if they offer a travel clinic service.

• Blackburn Travel Clinic – 01254 690496

• Manchester Travel Vaccination Clinic /Nomad Travel – 01341 555061

• Accrington Pharmacy - 01254 391699

• Accrington Late Night Pharmacy - 01254 351111

• Asda Pharmacy - 01254 306410

• Huncoat Pharmacy - 01254 238823

• Oswaldtwistle Pharmacy - 01254 399898

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Peel House Medical Practice • Accrington Pals Primary Care Centre, 1 Paradise Street, Accrington, BB5 2EJ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.