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.
Personal Details
Please double check you've entered the correct email address
May be used to identify you
Dates and Trip Details
Holiday Type: *
Please select all that apply
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?: *
Signed & Dated

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