Travel Risk Assessment

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Date of Travel

If you are travelling within the next 6 weeks we are unable to process your form. The practice needs time to review your form, asses your requirements and arrange appointments if required. Please complete a separate form for each person travelling. If you are travelling in the next 6 weeks you will need to contact a private travel clinic to discuss vaccination requirements

Your departure date is less than 6 weeks away, please contact the practice.

You have entered a date in the past, please try again

You cannot continue with this submission: *

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Personal Details

Please double check you've entered the correct email address

Gender: *

May be used to identify you

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Dates and Trip Details

Date of Departure:

Holiday Type: *

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

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Personal Medical History

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?:

Signed & Dated

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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MAIN SURGERY

Trumpington Street Medical Practice
56 Trumpington Street
Cambridge
CB2 1RG

Telephone: 01223 361611
Out-Of-Hours: 111

BRANCH SURGERY

Trumpington Medical Centre
Level 2 Clay Farm Centre
Hobson Square, Trumpington
Cambridge, CB2 9FN

Telephone: 01223 845185
Out-Of-Hours: 111

PRACTICE POLICIES

Find out more about the policies and procedures we adhere to at Trumpington Street Medical Practice

READ ABOUT OUR POLICIES

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Trumpington Street Medical Practice

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Travel Risk Assessment

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BRANCH SURGERY

PRACTICE POLICIES

FRIENDS AND FAMILY TEST

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