Travel Risk Assessment

 
Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

All questions marked with a * are mandatory

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.
  • We also may need to order the vaccinations that you require.
Processing
Personal Details
Please double check you've entered the correct email address
May be used to identify you
Processing
Dates and Trip Details
Holiday Type: *
Type of Trip: *
Accommodation: *
Travelling: *
Staying in area which is: *
Planned Activities: *
  
Processing
Personal Medical History
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?:
Processing
Signed & Dated
Processing

Privacy Consent

Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.

Providing NHS Services

Contact

Fernbank Surgery
Lytham Primary Care Centre
Victoria Street, Lytham
FY8 5DZ

Freckleton Health Centre
Douglas Drive, Freckleton
Lancashire, PR4 1RY

Telephone: 01253 202040

The Practice

Quick Links

The Care Quality Commission Inspected and rated Good

© Tree View Designs Ltd. All rights reserved.