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

If you are human, leave this field blank.

Full Name *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Gender:

Male

Female

Indeterminate

Country of Origin:

Date of Departure:

Please use this date format: DD/MM/YYYY

Total length of trip:

Please give details of country to be visited, exact location or region, city or rural, and length of stay:

Holiday type:

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking/adventure

Visiting friends/family

Pilgrimage

Type of trip:

Holiday

Business

Expatriate

Volunteer work

Healthcare work

Pleasure

Other

Accommodation:

Hotel

Relatives / family home

Hostel

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Medical tourism

Diving

Other

Additional information:

Do you plan to travel abroad again in the future?

Yes

No

Are you fit and well today?

Yes

No

Details:

Any allergies including food, latex, medication:

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

Yes

No

Details:

Does having an injection make you feel faint?

Yes

No

Details:

Any surgical operations in the past, including e.g. your spleen or thymus gland removed:

Recent chemotherapy/radiotherapy/organ transplant?

Yes

No

Details:

Anaemia?

Yes

No

Details:

Bleeding /clotting disorders (including history of DVT)?

Yes

No

Details:

Heart disease (e.g. angina, high blood pressure)?

Yes

No

Details:

Diabetes?

Yes

No

Details:

Disability?

Yes

No

Details:

Epilepsy/seizures?

Yes

No

Details:

Gastrointestinal (stomach) complaints?

Yes

No

Details:

Liver and or kidney problems?

Yes

No

Details:

HIV/AIDS?

Yes

No

Details:

Immune system condition?

Yes

No

Details:

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

Yes

No

Details:

Neurological (nervous system) illness?

Yes

No

Details:

Respiratory (lung) disease?

Yes

No

Details:

Rheumatology (joint) conditions?

Yes

No

Details:

Spleen problems?

Yes

No

Details:

Any other conditions?

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

Yes

No

Don't Know

Women Only

Are you pregnant or planning pregnancy or breast feeding?

Are you planning pregnancy while away?

Yes

No

Details:

Have you undergone FGM / been cut / circumcised?

Yes

No

Details:

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

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

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick-borne Enceph (TBE):

BCG

MMR

Pneumococcal

COVID-19

Cholera

Other / Malaria tablets

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

Tetanus: *

Polio: *

Hepatitis A: *

Hepatitis B: *

Meningitis: *

Yellow Fever: *

Influenza: *

Rabies: *

Jap B Enceph: *

Tick-borne Enceph (TBE): *

Diptheria: *

Typhoid: *

BCG: *

MMR: *

Pneumococcal: *

COVID-19: *

Dates, brands, etc.

Cholera: *

Other / Malaria tablets please list here: *

Any additional information:

Signed: *

Date:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent - it may take up to 2 working days before I receive a reply.