• Risk Assessment form

    Your risk assessment will be undertaken by Dr Ravi Gowda, Consultant in Infectious Diseases and Travel Medicine. He has decades of experience in Tropical Medicine and travel health, and receives referrals from health care professionals throughout the region.
  • Why do I need to fill out a risk assessment?

    It is vital that we undertake an appropriate personal and destination risk assessment to ensure that any advice that we offer you is safe. Your medical condition or any medications that you are taking can potentially affect any vaccinations or medications that we may administer. So it is very important that we collect as much information as possible to reduce the risk of serious side-effects. We also need to make sure that we are able to give you appropriate advice if you are a high risk individual (for example you have a weakened immune system) So please take care in filling out this questionnaire.
  • Personal Details

  •  - -
    Pick a Date
  • Travel Details

  •  - -
    Pick a Date
  • Medical History

  • Consent for a child (less than 16 years) - Please note we cannot administer any vaccines without this consent

    If you are over the age of 16 please go straight to the following page
  • Please supply information on any vaccines or malaria tablets taken in the past

    You may leave this section blank if you are not aware of your previous vaccine history. Your GP practice is usually happy to give you your list of previous vaccinations. You can then bring it with you to your appointment. If you wish to email the list then you can do so securely to travelklinix@protonmail.com.
  • Your email will be used to contact you with any vital communications e.g. lab results, clinical issues, urgent notifications

  • Consent

  • Should be Empty: