Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Travel Risk Assessment

Travel Risk Assessment

Please supply information about your trip below

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Do you plan to travel abroad again in the future?

Type of Travel and Purpose of Trip

Please tick all that apply
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:

Please supply details of your personal medical history

Are you fit and well today?
Any allergies including food, latex, medication?
Have you had a severe reaction to a vaccine before?
Does having an injection make you feel faint?
Have you had any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Have you recently undergone radiotherapy, chemotherapy, organ transplant or steroid treatment?
Do you have any history or mental illness (including anxiety, depression)?
Do you or any close family members have epilepsy?
Are you pregnant, breast feeding or planning pregnancy while away?
Have you undergone FGM/been cut/circumcised?
Please specify if you suffer from any of the following:
Including diabetes, heart or lung conditions
Including prescribed, purchased or a contraceptive pill

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

Have you ever had any of the following vaccinations/malaria tablets?

Please state which year you had the vaccination(s):

*