Travel Risk Assessment

If you are travelling abroad it is essential that you book your appointment with the travel nurse well in advance of your departure date – about 6-8 weeks before you travel is ideal. We cannot guarantee appointment availability. Please complete the travel assessment form and bring it along to your appointment.

Travel Risk Assessment

Travel Risk Assessment

Section

Gender:
Please use this date format: DD/MM/YYYY
Type of trip:
Holiday type:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Are you fit and well today?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Recent chemotherapy/radiotherapy/organ transplant?
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?
Do you have any history or mental illness including depression or anxiety?
Neurological (nervous system) illness?
Respiratory (lung) disease?
Rheumatology (joint) conditions?
Spleen problems?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Women only

Are you planning pregnancy while away?
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):

*