Travel Risk Assessment

If you are travelling abroad please make sure you submit the form at least 6 weeks before your travel date in order for us to be able to accommodate vaccinations before you are due to travel.

To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Please ensure you check your junk email folder for a reply.

If your message is urgent, please call the practice on 01827 69283. This inbox is not monitored out of hours when the Practice is closed (between 18:30 and 08:00 or at weekends), if you need urgent assistance while we are closed, please call 111 or in an emergency dial 999.

Travel Risk Assessment

Travel Risk Assessment

About your trip

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

Holiday type:
Planned activities:
Accommodation:
Travelling:
Staying in area which is:
Type of trip:

Medical history

Are you fit and well today?
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?
Does having an injection make you feel faint?
Have you recently undergone radiotherapy, chemotherapy or organ transplant?
Anaemia?
Bleeding/clotting disorders (including history of DVT)?
Heart disease (e.g. angina, high blood pressure)?
Diabetes?
Additional needs or disability?
Do you or any first degree relatives have epilepsy?
Gastrointestinal (stomach) complaints?
Liver and or kidney problems?
HIV/AIDS?
Immune system condition e.g. blood cancer?
Mental health issues (including anxiety, depression)?
Neurological (nervous system) illness?
Respiratory (lung) disease?
Rheumatology (joint) conditions?
Spleen problems?
Including diabetes, heart or lung conditions
Including prescribed, purchased or a contraceptive pill
Have you ever had any of the following vaccinations / malaria tablets?

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

Dates, brand etc.
*