Travel Risk Assessment 2022

Please complete this form 8 weeks before your travel date

Last Updated: 21/02/2023

Your Details

Name *

Date of Birth *

ADDRESS *

Mobile Telephone Number *

I consent to the Practice communicating via SMS Text Messaging and Email *

Yes

Email Address *

Gender *

Male

Female

Trip Details

Departure Date *

Return date or overall length of trip *

Please give details of ALL countries, areas or cities to be visited, length of stay and how remote you will be from medical help *

Any future travel plans? *

Trip Description

Personal Medical History

Vaccination History

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Further Information