Travel Risk Assessment

THE VILLAGE SURGERY
Station Road, Southwater, West Sussex RH13 9HQ Telephone 01403 730016 www.southwatersurgery.co.uk

TRAVEL RISK ASSESSMENT
We need to perform a travel risk assessment before confirming which vaccines are recommended for your trip.

Having an awareness of all the travel health problems you may be at risk from on your trip prior to your appointment is essential.
www.fitfortravel.nhs.uk and www.nathnac.org prior to your consultation.


We require up to 4 working days to process this form.

PERSONAL DETAILS


DATES OF TRIP


ITINERARY


DESCRIBE YOUR TRIP (Please tick all that apply)


WOMEN ONLY


Travel vaccination or malaria history if not received here at the practice


Have you had all of your childhood vaccinations including MMR?


PERSONAL MEDICAL HISTORY


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HODZR