Travel health

Stay safe and healthy abroad

Please note; you must provide us with this form at least 8+ weeks before your intended travel date.

If you are travelling abroad you may need to be vaccinated. Please complete the form below and contact the practice on 0114 2850140 to book an appointment with a practice nurse to discuss this. It is important to make this initial appointment at least eight weeks before you travel so that the vaccines can take affect.

Some travel vaccines are ordered on a private prescription which cost more than the normal prescription charge. This is because not all travel vaccinations are included in the services provided by the NHS.

Travel vaccinations

Travel health questionnaire - Standard

Please complete this pre-travel full risk assessment form at least 8 weeks before you travel.

Your details

Name(Required)

First Last

Date of birth(Required)

Day

Month

Year

NHS number

Get help to find your NHS number online

Sex(Required)

Male

Female

Address(Required)

Postcode(Required)

Daytime telephone number(Required)

Travel details

Departure date(Required)

Day

Month

Year

Total length of trip(Required)

please provide number of days or weeks

What is the purpose of your trip?(Required)

Holiday

Business

Volunteer work

Healthcare worker

Staying in a hotel

Cruise ship trip

Visiting friends/family

Safari

Pilgrimage

Medical tourism

Backpacking

Camping/hostels

Organised adventure

Diving

Please tick all that apply

Country name(Required)

Country location or region(Required)

Length of stay

Will you be visiting a second country?(Required)

Yes

Second country name

Second country location or region

Length of stay in second country

Will you be visiting a third country?

Yes

Third country name

Third country location or region

Length of stay in third country

Will you be visiting a fourth country?

Yes

Fourth country name

Fourth country location or region

Length of stay in fourth country

Do you plan to travel abroad again in the future?(Required)

Yes

Your medical information

Have you any current health problems?(Required)

Enter N/A if you do not have any current health problems.

Have you any medical history of note? Are you currently undergoing chemotherapy/radiotherapy/ organ transplant?(Required)

Enter N/A if you have nothing to report

Current medication(Required)

Please include any prescribed, over the counter or purchased medication. Enter N/A if taking no form of medication.

Please list any allergies (if any)(Required)

e.g. food, latex, medication. Enter N/A if you have no allergies.

Have you had a serious reaction to a vaccine given to you before?(Required)

Yes

Please provide details here

Vaccination history

Have you ever had any of the following vaccinations / malaria tablets?(Required)

Tetanus

Polio

Cholera

Diphtheria

Typhoid

Meningitis

Yellow fever

Influenza

Rabies

Hepatitis A

Hepatitis B

Japanese encephalitis

Tick borne encephalitis

BCG

Pneumococcal

Malaria tablets

Other vaccination not listed

None of the above

Please provide approximate dates if you have received any of the above vaccinations

Women only

Are you pregnant?

Yes

Not sure

Number of weeks

Are you breastfeeding?

Yes

Are you planning a pregnancy whilst being away?

Yes

Not sure

Additional information

Please provide any additional information below

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

https://www.nhs.uk/conditions/travel-vaccinations/

Travel health checklist

https://www.nhs.uk/live-well/healthy-body/travel-health-checklist/

Travel Questionnaire

Please complete this pre-travel full risk assessment form at least 8 weeks before you travel.

Your details

Name(Required)

First Last

Date of birth(Required)

Day

Month

Year

NHS number

Get help to find your NHS number online

Sex(Required)

Male

Female

Address(Required)

Postcode(Required)

Daytime telephone number(Required)

Travel details

Departure date(Required)

Day

Month

Year

Total length of trip(Required)

please provide number of days or weeks

What is the purpose of your trip?(Required)

Holiday

Business

Volunteer work

Healthcare worker

Staying in a hotel

Cruise ship trip

Visiting friends/family

Safari

Pilgrimage

Medical tourism

Backpacking

Camping/hostels

Organised adventure

Diving

Please tick all that apply

Country name(Required)

Country location or region(Required)

Length of stay

Will you be visiting a second country?(Required)

Yes

Second country name

Second country location or region

Length of stay in second country

Will you be visiting a third country?

Yes

Third country name

Third country location or region

Length of stay in third country

Will you be visiting a fourth country?

Yes

Fourth country name

Fourth country location or region

Length of stay in fourth country

Do you plan to travel abroad again in the future?(Required)

Yes

Your medical information

Have you any current health problems?(Required)

Enter N/A if you do not have any current health problems.

Have you any medical history of note? Are you currently undergoing chemotherapy/radiotherapy/ organ transplant?(Required)

Enter N/A if you have nothing to report

Current medication(Required)

Please include any prescribed, over the counter or purchased medication. Enter N/A if taking no form of medication.

Please list any allergies (if any)(Required)

e.g. food, latex, medication. Enter N/A if you have no allergies.

Have you had a serious reaction to a vaccine given to you before?(Required)

Yes

Please provide details here

Vaccination history

Have you ever had any of the following vaccinations / malaria tablets?(Required)

Tetanus

Polio

Cholera

Diphtheria

Typhoid

Meningitis

Yellow fever

Influenza

Rabies

Hepatitis A

Hepatitis B

Japanese encephalitis

Tick borne encephalitis

BCG

Pneumococcal

Malaria tablets

Other vaccination not listed

None of the above

Please provide approximate dates if you have received any of the above vaccinations

Women only

Are you pregnant?

Yes

Not sure

Number of weeks

Are you breastfeeding?

Yes

Are you planning a pregnancy whilst being away?

Yes

Not sure

Additional information

Please provide any additional information below

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

I agree to the privacy policy.

Stay safe and healthy abroad

Please note; you must provide us with this form at least 8+ weeks before your intended travel date.

Travel vaccinations

Travel health questionnaire - Standard

Your details

Travel details

Your medical information

Vaccination history

Women only

Additional information

Travel health checklist

Travel Questionnaire

Your details

Travel details

Your medical information

Vaccination history

Women only

Additional information

Helpful links

Further Info