Travel Risk Assessment

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All questions marked with a * are mandatory

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary.

To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.
We also may need to order the vaccinations that you require.
Please be aware The Vine Medical Centre is not a registered Yellow Fever Centre and cannot provide this vaccination, if required you will need to make an appointment with a Yellow Fever Centre.

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Personal Details

Please double check you've entered the correct email address

May be used to identify you

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Dates and Trip Details

Do you plan to travel abroad again in the future?: *

Holiday Type: *

Please select all that apply

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

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Personal Medical History

Any allergies including food, latex, medication?: *

Have you ever had a serious reaction to a vaccine given to you before?: *

Have you had your spleen or thymus gland removed?: *

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?: *

Do you have epilepsy/seizures?: *

Does having an injection make you feel faint?: *

Do you have any history or mental illness including depression or anxiety?: *

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?: *

Are you pregnant?: *

Are you breast-feeding?: *

Are you planning pregnancy while away?: *

Have you undergone FGM / been cut / circumcised?: *

Have you ever had any of the following vaccinations / malaria tablets?:

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Signed & Dated

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Privacy Consent

This form collects personal and medical information about you and 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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The Vine Medical Centre
13 Tonbridge Road
Maidstone, Kent
ME16 8RL

Telephone: 01622 754 898

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