Travel Risk Assessment Form

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All questions marked with a * are mandatory

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.
  • We also may need to order the vaccinations that you require.
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Personal Details
Sex:
Please double check you've entered the correct email address
May be used to identify you
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Dates and Trip Details
Holiday Type: *
Please select all that apply
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Personal Medical History
Are you fit and well today?: *
Including food, latex, medication
Have you ever had a severe reaction to a vaccine given to you before?: *
Does having an injection make you feel faint?: *
Have you had any surgical operations in the past?: *
Including your spleen or thymus gland removed
Have you recently undergone radiotherapy, chemotherapy or organ transplant?: *
Do you have anaemia?: *
Do you have bleeding/clotting disorders?: *
Including history of DVT
Do you have heart disease?: *
Including angina, high blood pressure
Do you have diabetes?: *
Do you have epilepsy/seizures?: *
Do you have gastrointestinal (stomach) complaints?: *
Do you have liver and/or kidney problems?: *
Do you have HIV/AIDS?: *
Do you have an immune system condition?: *
Do you have any history or mental illness including depression or anxiety?: *
Do you have a respiratory (lung) disease?: *
Do you have a neurological (nervous system) illness?: *
Do you have any rheumatology (joint) conditions?: *
Do you have any spleen problems?: *
Including prescribed, purchased or a contraceptive pill
Have you ever had any of the following vaccinations / malaria tablets?:
Women Only
Are you pregnant?: *
Are you breast feeding?: *
Are you planning pregnancy while away?: *
Have you undergone FGM/been cut/circumcised?: *
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Signed & Dated
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