Travel Risk Assessment

Section

Please use this date format: DD/MM/YYYY
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Do you plan to travel abroad again in the future?
Type of trip:
Accommodation:
Planned activities:
Are you fit and well today?
Any allergies including food, latex, medication?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Medical Conditions

Are you pregnant?
Are you breast feeding?
Are you planning pregnancy?
Please select all that apply:
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):