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

Section

Travel Information

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Have you taken out travel insurance for this trip? *
Do you plan to travel abroad again in the future?
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:

Personal Medical History

Are you fit and well today? *
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before? *
Do you have a tendency to faint with injections? *
Any surgical operations in the past, including open heart surgery/spleen/thymus gland removal? *
Recent chemotherapy/radiotherapy/organ transplant? *
Anaemia? *
Bleeding/clotting disorders (including history of DVT)? *
Heart disease including angina/high blood pressure? *
Diabetes? *
Additional needs and/or disability? *
Epilepsy/seizures (or in a first degree relative)? *
Gastrointestinal (stomach) complaints? *
Liver and/or kidney problems? *
HIV/Aids? *
Immune system condition ie blood cancer? *
Mental health issues including depression/anxiety? *
Neurological disorders (nervous system)? *
Respiratory disease? *
Rheumatology conditions? *
Spleen problems? *
Have you or anyone in your family undergone FGM/been cut/circumcised? *
Are you or your partner pregnant or planning a pregnancy? *
Are you breastfeeding?
Including prescribed, purchased or a contraceptive pill.

Previous Vaccinations

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

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

Enter full name
*