Travel Risk Assessment

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Personal Details

Our travel vaccinations service has now resumed, please note we require at least 8 weeks’ notice before the travel date to ensure we can source and provide the necessary vaccinations.

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Gender: *

May be used to identify you

Dates and Trip Details

Holiday Type: *

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

Personal Medical History

Anaemia: *

Bleeding/Clotting disorders (including history of DVT): *

Heart Disease (e.g. angina, high blood pressure): *

Diabetes: *

Epilepsy/seizures: *

Gastrointestinal (stomach) complaints: *

Liver or kidney problems: *

HIV/AIDS: *

Immune System Condition: *

Neurological (nervous system) illness: *

Respiratory (lung) conditions: *

Rheumatology (joint) conditions: *

Spleen problems: *

Are you pregnant: *

Are you breast feeding?: *

Are you planning pregnancy while away?: *

Have you undergone FGM / been cut / circumcised: *

Including diabetes, heart or lung conditions

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?:

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CONTACT DETAILS

Lakeside Healthcare at Yaxley
The Health Centre
Landsdowne Road
Yaxley
Peterborough
PE7 3JL

Telephone: 01733 240 478

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