Travel Risk Assessment


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:
Are you fit and well today? *
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? *
Do you or any close family members have bleeding/clotting disorders (including history of DVT)? *
Do you have heart disease (e.g. angina, high blood pressure)? *
Do you have liver and/or kidney problems? *
Do you have HIV/Aids? *
Do you have immune system condition? *
Do you have neurological (nervous system) illness? *
Do you have rheumatology (joint) conditions? *
Do you have respiratory (lung) disease? *
Do you have spleen problems? *
Do you have anaemia? *
Have you had any surgery or treatment to your spleen or thymus gland, including your spleen or thymus gland removed? *
Have you recently undergone radiotherapy, chemotherapy/organ transplant? *
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):

Travel Medicines

We offer a range of travel medicines to help to keep you healthy and enjoying your holiday. They can be ordered from our dispensary using this form. We require one week’s notice to process your order, but if you require them sooner let us know and we will see if we can help. Payment will be required at the time of ordering and must be via cash or cheque please.

Anyone requiring medication to help with fear of flying or altitude sickness must speak to their GP.

Please select the medicines you wish to order: