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 use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
Staying in area which is:
Planned activities:
Do you plan to travel abroad again in the future?
Are you fit and well today?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Recent chemotherapy/radiotherapy/organ transplant?
Bleeding /clotting disorders (including history of DVT)?
Heart disease (e.g. angina, high blood pressure)?
Gastrointestinal (stomach) complaints?
Liver and or kidney problems?
Immune system condition?
Do you have any history or mental illness including depression or anxiety?
Neurological (nervous system) illness?
Respiratory (lung) disease?
Rheumatology (joint) conditions?
Spleen problems?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Women Only

Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised?

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

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

Dates, brands, etc.