NHS TRAVEL RISK ASSESSMENT FORM

Travel risk assessment form - to be completed by traveller prior to appointment for NHS vaccines

Last Updated: 17/01/2025

Name:

Name
Address:

Address
Date of birth:

Date of birth:
Male or Female

Male or Female
Telephone Number:

Telephone number (optional)
Email Address:

Email Address:
Mobile Number:

Mobile Number:
Date of Departure:

Date of Departure:
Total Length of trip:

Total Length of trip:
Country to be visited:

How long are you staying for?

Exact location or region

City or Rural
Type of travel and purpose of trip

Type of travel and purpose of trip
Please supply details of your personal medical history

Any allergies including food, latex or medication?

Severe reaction to a vaccine before?

Are you immunocompromised?

Are you pregnant? (optional)
Information

Chew Medical Practice no longer provides a full travel clinic service. We provide the agreed NHS services for free and do not provide any non-NHS vaccines or general travel advice.

NHS - Free vaccines (given by practice)

HEP A

Polio, Diptheria & Tetanus

Typhoid injection or oral

Cholera - This would need to be ordered

Use the websites below to idnetify which vaccines you will need by searching for your destination country. Please review your immunisation history on the NHS App or request a copy from reception to check which vaccinations you already have.

https://www.fitfortravel.nhs.uk/destinations

https://travelhealthpro.org.uk/

You can access advice about travelling abroad, including the latest information on safety and security, entry requirements and travel warnings here:

Foreign travel advice - GOV.UK

It remains your responsibilty to seek travel advice for the countries you are visiting. Please see our travel advice leaflet or our website for further details on private clinics who can support with non-NHS travel vaccinations advice.
Free NHS Vaccines available

HEP A

Polio, Diptheria & Tetanus

Typhoid (injection or oral)

Cholera (this would need to be ordered)

Please put which FREE NHS vaccines are required
Your form will be reviewed by one of our Nurses. Once your eligibility for the vaccine(s) is confirmed you will be contacted to arrange an appointment

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NHS TRAVEL RISK ASSESSMENT FORM

Name:

Address:

Date of birth:

Male or Female

Telephone Number:

Email Address:

Mobile Number:

Date of Departure:

Total Length of trip:

Country to be visited:

Type of travel and purpose of trip

Please supply details of your personal medical history

Information

Free NHS Vaccines available

Your form will be reviewed by one of our Nurses. Once your eligibility for the vaccine(s) is confirmed you will be contacted to arrange an appointment