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.

Travel Risk Assessment

Travel Risk Assessment

Section

Please use this date format: DD/MM/YYYY
Have you taken out 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, medication?
Severe reaction to 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/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?
Have you undergone FGM / been cut / circumcised?

Women Only

Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Including prescribed, purchased or a contraceptive pill
Please supply information on any vaccines or Malaria tablets taken in the past

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

*