Travel Risk Assessment

If you are travelling abroad, you may need; vaccinations, malaria tablets and health advice depending on your destination.

In order for us to assess your needs properly, please complete this form and make an appointment with the Practice Nurse by calling 0121 3591539 as soon as possible (ideally at least 4 weeks before travel).

Please complete one form per traveller as you are assessed individually.

Please see the below resources for travel advice:

Travel Risk Assessment

Travel Risk Assessment

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
Staying in area which is:
Planned activities:
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?

Please state which year you had the vaccination(s):