Travel Risk Assessment

Fields marked with a red * asterisk are compulsory.

Please fill out this form. We will confirm the accuracy of the details when you attend your appointment. By using this form you will be sending information about yourself across the internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concern you please use another method to notify us of your information.

Travel Risk Assessment Form

Personal Information

Name *

First

Last

Date of Birth *

Your Country of Origin

Your Gender

Telephone / Mobile Numbers

Email *

Confirm Email

Please supply information about your trip in the sections below:

Date of Departure *

Date of Return

Please list the countries you are visiting, their exact location or region, city or rural and length of stay

Please list as follows e.g.: Africa / Kenya / City / 21 days

Type of travel and purpose of trip

Type of Trip *

Business
Pleasure
Other

Accommodation *

Hotel
Staying with Relative/Friends
Family Home
Other

Who are you Travelling with? *

Alone
With family/friends
In a Group

Which area are you staying *

Urban
Rural
Altitude

Planned Activities *

Safari
Adventure
Other

Please provide any further information in the box below:

Details of Your Medical History

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions) *

Are you on any current or repeat medication? *

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

Have you ever had a serious reaction to a vaccine given to you before? *

Yes
No
Don't know

Do you have a tendancy to faint with injections? *

Yes
No
Don't know

Do you or any close family members have epilepsy? *

Yes
No
Don't know

Do you have any history or mental illness including depression or anxiety? *

Yes
No
Don't know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes
No
Don't know

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this? *

Yes
No
Don't know

Please type below any further information which may be relevant:

Vaccination Details

Please provide any details if you can of all that you ticked above

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS.

Consent *

I consent to the practice collecting and storing my data from this form.

Chiodini J, Boyne L, Grieve S, Jordan A. (2007) Competencies: An Integrated Career and Competency Framework for Nurses in Travel Health Medicine. RCN, London.
Field VK, Ford L, Hill DR, eds. (2010) Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK

The Castle Practice

The Health Centre | Taylors Avenue | Carrickfergus | BT38 7HU

Personal Information

Please supply information about your trip in the sections below:

Type of travel and purpose of trip

Details of Your Medical History

Vaccination Details

Privacy Policy

CONTACT

HOURS

POLICIES

LINKS

COVID SPRING BOOSTERS

FOR PATIENTS AGED 75 AND OVER

AND ALL IMMUNOSUPPRESSED PATIENTS

FINAL CLINIC DATE

16.06.2026

WE WILL NOT HAVE ANY VACCINATIONS

AVAILABLE AFTER THIS DATE

WE HAVE BEEN CONTACTING PATIENTS BY

TEXT AND TELEPHONE CALLS

**PLEASE CONTACT THE

PRACTICE ANY DAY AFTER 11:00 AM

TO BOOK YOUR APPOINTMENT**

028 9331 5805

07513 985 168

07873 214 100

07873 211 433

Personal Information

Please supply information about your trip in the sections below:

Type of travel and purpose of trip

Details of Your Medical History

Vaccination Details

Privacy Policy

CONTACT

HOURS

POLICIES

LINKS

** COVID SPRING BOOSTERS **

FOR PATIENTS AGED 75 AND OVER

AND ALL IMMUNOSUPPRESSED PATIENTS

** FINAL CLINIC DATE **

16.06.2026

WE WILL NOT HAVE ANY VACCINATIONS

AVAILABLE AFTER THIS DATE

WE HAVE BEEN CONTACTING PATIENTS BY

TEXT AND TELEPHONE CALLS

**PLEASE CONTACT THE

PRACTICE ANY DAY AFTER 11:00 AM

TO BOOK YOUR APPOINTMENT**

028 9331 5805

07513 985 168

07873 214 100

07873 211 433

COVID SPRING BOOSTERS

FINAL CLINIC DATE