Travel Vaccination Risk Assessment Form

Dear Patient 

Thank you for your Travel Vaccination enquiry.  

Please complete this form 10 - 12 weeks in advance of your travel date.  

The practice does not provide a service for last minute travellers – within 8 weeks of your travel date or if you are travelling to more than one country.

If your travel date is less than 8 weeks or you are travelling to more than one country, please seek urgent travel advice from a private travel vaccination clinic:

Oakenhall Medical Practice provides the following vaccinations free under the NHS, where required for travel purposes:

•	Hepatitis A 
•	Typhoid
•	Tetanus
•	Diphtheria
•	Polio
•	Cholera – only available by prescription and a prescription charge will be requested by your usual Community Pharmacy.

We do not currently offer private vaccinations i.e., ones other than those above that the NHS does not cover the cost of.  For these please contact a private travel vaccination clinic. 

If anti-malarial medication advice is required, you will be directed to contact your Community Pharmacy.  

If your travelling date is more than 10 -12 weeks ahead:

•	Please complete the Travel Vaccination Risk Assessment Form overleaf →
•	Please return the completed form to Reception where we will book you an appointment. 

Travel Vaccination Risk Assessment Form

To be Completed by Traveller 10 – 12  Weeks Prior To Travel	
Name:	Date of Birth:	
Address:

	Male       □

Female   □	
Telephone Number:
Can we leave a message?  Yes    /    No	Mobile Number:
Can we leave a message?  Yes    /    No	

Please supply information about your trip in the sections below:	
Date of Departure:	Total Length of Trip:	
County to be visited	Exact location or region	City or Rural	Length of Stay	

Have you taken out travel insurance for this trip?	
Type of Travel and Purpose of trip – please tick all that apply	
□ Holiday	□ Staying in Hotel	□ Backpacking	Additional Information/ high risk activities e.g. Tattoos	
□ Business Trip	□ Cruise Ship Trip	□ Camping/hostels		
□ Expatriate	□  Safari	□ Adventure		
□ Volunteer Work	□ Pilgrimage	□ Diving		
□ Healthcare Worker	□ Medical Tourism	□ Visiting family/friend		

Personal Medical History	
Please give details of any medical history or medications (including over the counter) that may not be on your medical records at the practice:
	
Further Details	N	Y	If yes, Please give further details	
Do you have any allergies (e.g. eggs, nuts, latex,
Antibiotics, medication				
Have you ever had a serious reaction to a vaccine that you have previously received?				
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?				
Women only – are you pregnant, planning a pregnancy or breast feeding?				
I confirm the information I have provided is accurate to my knowledge:

Signed:                                                             Date Completed: