Pre-Travel Health Assessment

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It is important to make this initial appointment as early as possible – We will be unable to offer travel appointments to anyone travelling with less than (12 weeks) prior to their departure date as in some cases a second appointment will be required with the practice nurse to complete a course of vaccinations. Some vaccines have to be ordered as they are not a stock vaccine. Your second appointment needs to be at least 2 weeks before you travel to allow the vaccines to work. There is still no guarantee we will be able to accommodate your travel request as we have limited capacity if you do give us a minimum of 12 weeks notice. You may need to need to book an appointment at a private travel clinic such as the Winchester travel clinic.
Name*
Date of Birth*
dd-mm-yy or dd/mm/yy
Tel No.
Mobile No.
(A nurse will contact you if you are up to date with all vaccines required. Please therefore provide a daytime and mobile number.)
Email*
(The nurse will email all the relevant travel information & what type & length of appointment to make. Please ensure you check your spam/junk mailbox)
Details of Trip - Countries to be visited (including stopovers)*
Departure Date*
dd-mm-yy or dd/mm/yy
Length of Stay (Days)*
Type of Accommodation (Hotel, camping, hostels etc)*
Will you be in remote areas with no medical help?*
Past Medical History
If you answer YES to any questions the Nurse will discuss this further at the time of your appointment.
Do you have any long-term medical conditions?*
Do you have a history of epilepsy?*
Have you everbeen treated for a psychological disorder? e.g. depression, anxiety, etc.*
Have you had your spleen removed?*
Are you taking any medication?*
Have you everhad a bad reaction to a vaccine?*
Do you have any allergies?*
Are you pregnant, breast feeding or planning a pregnancy?*
Are you HIV positive?*
Have you recently received radiotherapy or chemotherapy?*
Have you ever suffered from psoriasis?*
Previous Vaccinations

Pre-Travel Health Assessment

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