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.

For more information and guidance, please visit our Travel Guidance page.

Travel Risk Assessment

Travel Risk Assessment

Gender:
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 again in the future?
Type of travel and purpose of trip - please tick all that apply

Please supply details of your personal medical history

Bleeding/clotting disorders (including history of DVT)
Any allergies including food, latex, medication?
Severe reaction to a vaccine previously?
Tendancy to faint with injections?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Recent chemotherapy/radiotherapy/organ transplant?
Any mental health issues (including anxiety, depression)?
Any spleen problems?
Any other conditions?

Women only

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


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

Form devised and created by Jane Chiodini © Updated 2018