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 you book an appointment.

Travel Risk Assessment

Travel Risk Assessment

Gender: *
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY.
Have you taken our travel insurance for this trip?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip - please tick all that apply

Please supply details of your personal medical history

Are you fit and well today?
Any allergies including food, latex or medication?
Severe reaction to a vaccine before?
Tendency to faint with injections?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed?
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 kidney problems?
HIV / AIDS
Immune system condition?
Mental health issues (including anxiety, depression)?
Neurological (nervous system) illness?
Respiratory (lung) disease?
Rheumatology (joint) conditions?
Any other conditions?

Women only

Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?

Please supply information on any vaccines or malaria tablets taken in the past