Travel Risk Assessment Form | Quayside Medical Practice

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If you are travelling in 12 weeks or less, please contact your local travel clinic directly. Not all vaccines are available on the NHS — please refer to travelhealthpro.org.uk for further information.

How this works

Fill in the form below as fully as you can — the more detail you give, the better we can advise you before you travel.
Download your completed form. Scroll to the bottom and click "Download / print my completed form", then choose Save as PDF in the print window.
Email it to us before your appointment: send the saved PDF to r.quayside@nhs.net. We need to receive this in advance — please don't wait and bring it with you instead.

Your details

Name

Date of birth

Address

Contact number

Gender

Your trip

Country(ies) to be visited

Date of departure

Total duration of trip

Where will you mostly be staying? (tick all that apply)

Type of travel and purpose of trip (tick all that apply)

Your medical history

For each question, please tick Yes or No, and add any details that might help us.

Current medication

Are you currently taking any medication? (including prescribed, purchased or the contraceptive pill)

Vaccination & malaria tablet history

Please tick any of the following you've had before, and roughly when if you can recall.

Anything else we should know?

Any additional information

Declaration & signature

Full name (typed as signature)

Date form signed

STAFF ONLY

Admin use only

Patients: you can skip this — please log the form as received in EMIS.

Staff member name

Date logged in EMIS

Finished? Click below, then choose "Save as PDF" in the print window. Once it's saved, email it to r.quayside@nhs.net — we need to receive this before your appointment, so please don't wait and bring it with you instead. Completing this page alone does not send it to us.

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