St Catherine's Surgery

First + Second Floor, Wing 4, St Catherine's Health Centre, Church Road, Birkenhead, Wirral, CH42 0LQ

Telephone: 0151 643 6700

cmicb-wi.stcatherinessurgery@nhs.net

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Travel Risk Assessment Form

If you are travelling abroad in the next 3 months and think you may need a vaccination for the countries you are visiting, please complete and submit this form. Once the form has been submitted, it will be reviewed by the practice nurse and we will contact you to advise if vaccinations are needed and book an appointment.

It is important to advise us at least 6 weeks before you travel so that we have time to review the form and book you an appointment. Additionally there is often an incubation time to allow the administered vaccine to become effective.
Name(Required)
DD slash MM slash YYYY

Please supply information about your trip in the sections below

MM slash DD slash YYYY
(Required)
Country to be visited
Exact location or region
City or rural
Length of stay
 
Have you taken out travel insurance for this trip?(Required)
Do you plan to travel abroad again in the future?(Required)
Type of travel and purpose of trip - Please tick all that apply(Required)

Please supply details of your personal medical history

Are you fit and well today(Required)
Any allergies including food, latex, medication(Required)
Severe reaction to a vaccine before(Required)
Tendency to faint with injections(Required)
Any surgical operations in the past, including e.g. your spleen or thymus gland removed(Required)
Recent chemotherapy/radiotherapy/organ transplant(Required)
Anaemia(Required)
Bleeding /clotting disorders (including history of DVT)(Required)
Heart disease (e.g. angina, high blood pressure)(Required)
Diabetes(Required)
Disability(Required)
Epilepsy/seizures(Required)
Gastrointestinal (stomach) complaints
Liver and or kidney problems(Required)
HIV/AIDS(Required)
Immune system condition(Required)
Mental health issues (including anxiety, depression)(Required)
Neurological (nervous system) illness(Required)
Respiratory (lung) disease(Required)
Rheumatology (joint) conditions(Required)
Spleen problems(Required)
Any other conditions?(Required)
Are you pregnant? (Women only)
Are you breast feeding? (Women only)
Are you planning pregnancy while away? (Women only)
Have you undergone FGM / been cut / circumcised (Women only)

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

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