Travel Risk Assessment
Travel Risk Assessment – v01 ‐ 25/25/2018
The Independent General Practice Reference Number
The Independent General Practice (IGP) provides private healthcare services in the form of medical consultation, examination, treatment, immunisation,
diagnosis and medical management services. As part of this service, IGP will process personal and sensitive information, which will be relevant,
proportional and limited to the patient’s individual circumstances, symptoms or requirements.
The IGP may share your data with additional third parties such as clinical experts, specialists, consultants, screening centres, laboratories, referrers
and/or nominated pharmacy in the provision of medical services. IGP and any third parties processing this information are required to ensure that they
meet an appropriate level of information security, confidentiality and the standards set by the General Data Protection Regulation (GDPR). As a
healthcare provider, we have a legal responsibility to retain medical records for a minimum of 10 years. For more information, IGP’s Privacy Policy and
Patient Guide is available on reception or at www.theigp.co.uk.
Title Date of Birth (DD/MM/YYYY)
First Name Last Name
Please provide details of your travel itinerary and purpose of visit
Destination(s) Date of Travel: Length of stay Away from medical help, if so, how long for?
Type of Trip: Business Pleasure Other
Holiday type: Package Self‐Organised Back Packing
Camping Cruise Ship Trekking
Accommodation: Hotel Relatives / Family Home Other
Company: Alone With Family / Friend(s) In a Group
Area: Urban Rural Altitude
Planned activities: Safari Adventure Other
Vaccination History ‐ Have you ever had any of the following vaccinations / Malaria tablets and if so when?
Diphtheria Tetanus Polio
Whooping Cough Hepatitis A Typhoid
Cholera Hepatitis B Rabies
Jap B Encephalitis Tick‐Borne Meningitis ACWY
Yellow Fever Malaria Other
Please provide details of any other vaccine(s) you have had:
Do you have a history of serious illness such as blood disorder, poor immunity, diabetes, heart, lung, thymus, etc.? Yes No
Are you on any current medication? Yes No
Do you have any allergies (eggs, antibiotics, nuts) or have you had a serious reaction to a vaccine given to you before? Yes No
Does having an injection make you feel faint? Yes No
Do you or any close family members have epilepsy? Yes No
Do you have any history or mental illness including depression or anxiety? Yes No
Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Yes No
Are you pregnant or planning pregnancy or breast feeding? Yes No
Have you taken out travel insurance & informed the insurance company of any medical condition? Yes No
If YES to any of the above, or if you have any further information which may be relevant please provide details: