Using the NHS App for Family members

Name(Required)

First Last

Date of Birth(Required)

Gender

Male

Female

Non-binary

Prefer to self-describe

Email

Phone

Details of your trip

Date of departure(Required)

Length of trip (days)(Required)

Do you plan to travel abroad again in the future?

Yes

No

Not sure

Have you taken out travel insurance for this trip?

Yes

No

Are you travelling to more than one country?

Yes, multiple countries

No, one country

Destination

Country to be visited(Required)

Exact Location or Region

City or Rural(Required)

City

Rural

Length of stay (days)(Required)

Destinations

First country to be visited(Required)

Exact Location or Region

City or Rural(Required)

City

Rural

Length of stay (days)(Required)

Second country to be visited(Required)

Exact Location or Region

City or Rural(Required)

City

Rural

Length of stay (days)(Required)

Third country to be visited(Required)

Exact Location or Region

City or Rural(Required)

City

Rural

Length of stay (days)(Required)

Please supply information on any vaccines or malaria tablets taken in the past

Tetanus/polio/diphtheria

MMR

Influenza

Typhoid

Hepatitis A

Hepatitis B

Pneumococcal

Cholera

Meningitis

Rabies

Japanese Encephalitis

Tick Borne Encephalitis

Yellow fever

BCG

Other

Malaria Tablets

Any additional information

Using the NHS App for Family members

Travel Risk Assessment Form

Details of your trip

Destination

Destinations

Travel and Purpose of your Trip

Please supply details of your personal medical history

Women Only

Please supply information on any vaccines or malaria tablets taken in the past