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Travel Health Assessment Form

Travel Health Service

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COVID-19: Latest information on appointments, visiting, vaccinations and testing.

The form will take approximately 5 minutes to complete. If you have any difficulties completing it, or wish to contact the department please do so on 0800 130 3120.

Please complete the travel risk assessment at least 6-8 weeks before travelling. If you are completing this form less than 6 weeks before travel we may not be able to offer travel immunisation.

Ensuring the information is accurate helps our nurses determine the risk and need of the individual travelling.

Once your travel risk form is submitted our Travel health team will review it. They will contact you by telephone in the next few days to discuss and confirm your travel immunisation requirements. At this time they will also book you in for any required immunisations or direct you to a local pharmacy for any non NHS treatments or immunisations.

    Your name *

    Your email *

    Your Date of Birth * dd/mm/yyyy

    Contact number *

    Locality *

    Are you contacting regarding a booster of a previous travel vaccination? *

    Please state the Vaccine booster you require *

    Is there more than one person travelling with you? *

    Please list others travelling with you *

    Date of Departure * dd/mm/yyyy

    Date of Return * dd/mm/yyyy

    Please list countries you plan to visit *

    Please give details of length of stay and how remote you'll be from medical help *

    Reason for travel? *

    Please describe the reason for travel *

    Please select the type of holiday *

    Please describe the other type of holiday *

    Select the type of accommodation you will be staying in *

    Please describe the other type of accommodation *

    The area you are staying is best described as *

    Please give indication of planned activities *

    Please describe the other type of activities you have planned *

    Please detail any recent or past medical history of note below, Please include conditions such as diabetes, heart/lung conditions, Immune problems or Cancer *

    Please detail any current or repeat medications *

    Do you have any allergies, for example eggs, antibiotics, nuts? *

    Please enter any additional information you would like to share with the Travel Health Nurse you feel will help inform the Nurse before your contacted (optional)

    By submitting this form you agree this information is accurate and understand the information provided will be used to assess travel health needs. If you have not given accurate information the advice provided may be incorrect. You also agree to the NHS contacting you about your submission to arrange appointments if required.

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    In an Emergency call 999 for health advice and reassurance call NHS24 on 111.
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