RMP - Travel Risk Assessment

RMP - Travel Risk Assessment

If you require any vaccinations relating to foreign travel you need to firstly complete the attached form and hand into the reception office. At this time an appointment will be made with the practice nurse approximately one week later for a telephone consultation to discuss your travel arrangements. This will include the countries and areas you are visiting to determine which vaccinations are required. It is important to make this initial appointment as early as possible (minimum of 6 weeks prior to travel), as a second appointment will be required with the Practice Nurse to actually receive the vaccinations.

  • Your Details

    Date of Birth
    For example, 15 3 1984
    Gender

  • Trip Details

    Departure Date
    For example, 15 3 1984

  • Trip Description

    Purpose of Trip (optional)
    Type of Trip (optional)
    Accommidation (optional)
    Travelling (optional)
    Location Type (optional)
    Activity type (optional)

  • Personal Medical History

    Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)? (optional)
    Does having an injection cause you to feel faint? (optional)
    Do you or any close family members have epilepsy? (optional)
    Do you have any history of mental illness including depression or anxiety? (optional)
    Have you recently undergone radiotherapy, chemotherapy or steroid treatment? (optional)
    Have you taken out travel insurance? (optional)
    If you have a medical condition, have you told your insurance company about it? (optional)
    Are you pregnant, planning pregnancy or breast feeding? (optional)

  • Vaccination History

    Have you ever had any of the following vaccinations / tablets and if so, when? (optional)
    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
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Page last reviewed: 29 September 2023
Page created: 23 August 2022