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Stemax Consult Milton Keynes

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Travel Medicine Risk Assessment

Travel Medicine Risk Assessment | Stemax Consult

Travel Medicine Risk Assessment

Please complete this confidential online assessment before your travel health appointment at Stemax Consult. It takes around 5 minutes and helps our clinicians prepare the right advice and vaccinations for your trip.

Confidentiality: The information you provide, including health details, is used only by our clinical team to prepare for your consultation and is handled in line with our Privacy Policy and UK GDPR.
This form is not for emergencies. If you have an urgent medical concern, call 999 or attend your nearest A&E.
1
Your Details
2
Trip Details
3
Activities
4
Health Screening
5
Consent

Your Details

So we can identify your record and get in touch about your appointment.

Trip Details

Tell us about your itinerary so we can assess destination-specific risks.

Will you be travelling to rural or remote areas with limited access to medical care?
Have you travelled to this destination or a similar region before?

Planned Activities & Exposure Risks

Select anything that applies to your trip — this affects the vaccines and advice we recommend.

Will your trip involve any of the following?
To your knowledge, is malaria a risk in the area(s) you are visiting?

Health Screening

This helps us identify anything that could affect which vaccines or medication are safe and suitable for you. You’re welcome to simply select “Yes” and discuss details in person rather than typing them here.

Do you have any existing medical conditions?
Are you currently taking any medications?
Do you have any known drug, food or vaccine allergies?
Do you have a weakened immune system? (e.g. due to illness, chemotherapy, immunosuppressant medication, HIV, or no spleen)
Do you have any chronic conditions such as diabetes, heart or respiratory disease, epilepsy, or a bleeding disorder?
Have you ever had a serious reaction to a vaccine?

Vaccination History & Consent

Finally, a few questions about your vaccination history, then please review and confirm below.

Are your routine UK vaccinations up to date? (e.g. MMR, tetanus/diphtheria/polio)
Have you previously had any of the following vaccines? (select all that apply)
Do you have a vaccination record or certificate you can bring to your appointment?