Online Travel Health Assessment Form 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. Please be aware that we require at least 6 weeks notice before you travel to allow time for your vaccinations. Name First Last Date of Birth Day Month Year Contact NumberEmail Enter Email Confirm Email Gender Female Male Details about your tripDate of Departure Day Month Year Trip duration Please give details of country to be visited, length of stay and how remote you will be from medical helpDescription of your tripPurpose of your trip Business Optional Pleasure Optional Other Optional Please specify Type of Trip Package Optional Self-Organised Optional Backpacking Optional Camping Optional Cruise Ship Optional Trekking Optional Accommodation Hotel Optional Friends/Family Optional Other Optional Please specify Travelling Alone Optional With Friends/Family Optional In a Group Optional Location Type Urban Optional Rural Optional Altitude Optional Activity type Safari Optional Adventure Optional Other Optional Please specify Personal Medical HistoryList all chronic medical conditions that you have (eg. diabetes, heart or lung conditions) OptionalList all allergies that you have (eg. eggs, nuts, antibiotics) OptionalIf you have had a serious reaction to a vaccine in the past, which vaccine was it? OptionalList all of your current medications (including oral contraception) OptionalHave you recently suffered from any infection (e.g heavy cold, flu or high temperature)? Yes Optional No Optional Does having an injection cause you to feel faint? Yes Optional No Optional Do you or any close family members have epilepsy? Yes Optional No Optional Do you have any history of mental illness including depression or anxiety? Yes Optional No Optional Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Yes Optional No Optional Have you taken out travel insurance? Yes Optional No Optional If you have a medical condition, have you told your insurance company about it? Yes Optional No Optional Are you pregnant, planning pregnancy or breast feeding? Yes Optional No Optional Write below any further information that might be relevant. OptionalVaccination HistoryHave you ever had any of the following vaccinations? Tetanus Optional Polio Optional Diphtheria Optional Typhoid Optional Hepatitis A Optional Hepatitis B Optional Meningitis Optional Yellow Fever Optional Influenza Optional Rabies Optional Japanese B Enceph Optional Tick Borne Optional Malaria Prophylaxis Optional Please add the dates of any of the above vaccines you have had OptionalThis form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the nhs. Please read our privacy policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form. Optional
