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.

Please note: there is a national shortage of some Travel Vaccinations and will be assessed on a case by case basis. Unfortunately the shortage is outside of our control.

Travel Risk Assessment

Travel Risk Assessment

If you are human, leave this field blank.

Full Name *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Gender:

Male

Female

Indeterminate

Your Country of Origin:

Date of Departure:

Please use this date format: DD/MM/YYYY

Total length of trip:

Please give details of country to be visited, exact location or region, city or rural, length of stay, and how remote you'll be from medical help:

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Yes

No

Don't Know

Do you plan to travel abroad again in the future?

Yes

No

Don't Know

Type of travel and purpose of trip:

Holiday

Business trip

Expatriate

Volunteer work

Healthcare worker

Staying in hotel

Cruise ship trip

Pilgrimage

Medical tourism

Backpacking

Camping / hostels

Adventure

Diving

Visiting friends / family

Any additional information:

Are you fit and well today?

Yes

No

Please provide details:

Any allergies including food, latex, medication?

Yes

No

List any allergies:

Have you ever had a serious reaction to a vaccine given to you before?

Yes

No

Please provide details:

Does having an injection make you feel faint?

Yes

No

Please provide details:

Any surgical operations in the past, including e.g. your spleen or thymus gland removed?

Yes

No

Please provide details:

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Please provide details:

Please select all that apply:

Anaemia

Bleeding /clotting disorders (including history of DVT)

Heart disease (e.g. angina, high blood pressure)

Diabetes

Disability

Epilepsy/seizures

Gastrointestinal (stomach) complaints

Liver and or kidney problems

HIV/AIDS

Immune system condition

Mental health issues (including anxiety, depression)

Neurological (nervous system) illness

Respiratory (lung) disease

Rheumatology (joint) conditions

Spleen problems

Other

Other - please specify:

Please provide further details about any of the conditions selected:

Have you undergone FGM / been cut / circumcised?

Yes

No

Please provide details:

Are you pregnant?

Yes

No

Please provide details:

Are you breast feeding?

Yes

No

Please provide details:

Are you planning pregnancy while away?

Yes

No

Please provide details:

List any current or repeat medications:

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

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick-borne Enceph (TBE):

Other / Malaria tablets

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

Tetanus: *

Polio: *

Hepatitis A: *

Hepatitis B: *

Meningitis: *

Yellow Fever: *

Influenza: *

Rabies: *

Jap B Enceph: *

Tick-borne Enceph (TBE): *

Diptheria: *

Typhoid: *

Other / Malaria tablets please list here: *

Any additional information:

Signed: *

Date:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent - it may take up to 2 working days before I receive a reply.