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Travel Risk Questionnaire

Some vaccinations are not available on the NHS and there will be a charge for these.

For further travel information please visit the following websites:

If, for any reason, you are unable to attend an appointment we would very much appreciate you contacting the surgery to cancel or re-arrange the appointment. Other patients may benefit from the released appointment.

Gender

Type of trip

Holiday type

Accommodation

Travelling

Staying in area which is

Planned activities

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?

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

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Registered address: Vine Medical Group, Forest End Site, Forest End, Waterlooville, Hampshire, PO7 7AH