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Travel Risk Assessment

Please complete the online form below before your appointment.  Alternatively click here to download the form, return the completed form to the surgery before your appointment.

 

1Travel Risk Assessment

2Please supply information about your trip

3Please supply details of your personal medical history

Women only

For everyone

4Please supply information on any vaccines or malaria tablets taken in the past

If you have had any of the vaccinations or malaria tablets referred to below please provide details.

5Any additional information

Travel risk assessment form devised by Jane Chiodini © 2012 in conjunction with resources below. 1. Chiodini J, Boyne L, Grieve S, Jordan A. (2007) Competencies: An Integrated Career and Competency Framework for Nurses in Travel Health Medicine. RCN, London. www.rcn.org.uk 2. Field VK, Ford L, Hill DR, eds. (2010) Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK. Form devised and created by Jane Chiodini © updated 2017


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Your Neighbourhood Professionals. Just a Click Away! Need care but want to stay in your own home? Donna Karpel
Little Bushey Surgery, California Lane, Bushey, Herts, WD23 1EZ
  • Telephone 020 8386 8888
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Your Neighbourhood Professionals. Just a Click Away! Need care but want to stay in your own home? Donna Karpel
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