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

If you are human, leave this field blank.

Section

Your country of origin:

Information about your Trip

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, and length of stay:

What modes of transport will you be using?

Have you taken out travel insurance for this trip?

Yes

No

Do you plan to travel abroad again in the future?

Yes

No

Type of Travel and Purpose of Trip

Type of trip:

Holiday

Business

Expatriate

Volunteer work

Healthcare work

Pleasure

Other

Holiday type:

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking/adventure

Visiting friends/family

Pilgrimage

Accommodation:

Hotel

Relatives / family home

Hostel

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Medical tourism

Diving

Other

Additional information:

Details of your Personal Medical History

Are you fit and well today?

Yes

No

Details:

Any allergies including food, latex, medication?

Yes

No

Details:

Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?

Yes

No

Details:

Tendency to faint with injections?

Yes

No

Details:

Any surgical operations in the past, including e.g. openheart surgery, spleen or thymus gland removal?

Yes

No

Details:

Recent chemotherapy/radiotherapy/organ transplant?

Yes

No

Details:

Anaemia?

Yes

No

Details:

Bleeding /clotting disorders (including history of DVT)?

Yes

No

Details:

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

Yes

No

Details:

Diabetes?

Yes

No

Details:

Disability?

Yes

No

Details:

Epilepsy/seizures?

Yes

No

Details:

Gastrointestinal (stomach) complaints?

Yes

No

Details:

Liver and or kidney problems?

Yes

No

Details:

HIV/AIDS?

Yes

No

Details:

Immune system condition?

Yes

No

Details:

Do you have any history or mental illness including depression or anxiety?

Yes

No

Details:

Neurological (nervous system) illness?

Yes

No

Details:

Respiratory (lung) disease?

Yes

No

Details:

Rheumatology (joint) conditions?

Yes

No

Details:

Spleen problems?

Yes

No

Details:

Any other conditions?

Are you or your partner pregnant or planning a pregnancy?

Yes

No

Details:

Are you breast feeding (if applicable)?

Yes

No

Details:

Have you or anyone in your family undergone FGM / been cut / circumcised?

Yes

No

Details:

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

Information on any Vaccines or Malaria Tablets Taken in the Past

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):

BCG

MMR

Pneumococcal

COVID-19

Cholera

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: *

BCG: *

MMR: *

Pneumococcal: *

COVID-19: *

Cholera: *

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 five working days before I receive a reply.