Travel risk assessment

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country to be visited, length of stay, and how remote you’ll be from medical help:

Holiday type:

Type of trip:

Business

Pleasure

Other

Accommodation:

Hotel

Relatives / family home

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Other

List any allergies:

Please write below any further information which may be relevant:

You should be up to date with routine vaccinations and boosters as recommended in the UK:

Diphtheria – Tetanus – Polio (DTP)
Measles – Mumps – Rubella (MMR)

The following travel vaccines are available free on the NHS from your GP surgery:

Diphtheria – Tetanus – Polio (DTP) – (Combined vaccine)
Measles – Mumps – Rubella (MMR)
Typhoid
Hepatitis A
Cholera

If you need any additional vaccinations, you will have to source these from a private travel clinic.

Please only answer the following question after you have done your research as per the cover sheet or our travel clinic page.

Tick the vaccines you think you require:

Attach the country of travel PDF document:

Maximum upload size: 67.11MB

I have read, understood and attached the country of travel PDF document from www.travelhealthpro.org.uk as instructed on the travel clinic page

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent – it may take up to 2 weeks before I receive a reply.

Signed:

Date:

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