Travel Risk Assessment

We offer a full travel advice and immunisation service. If you are travelling abroad, please complete and submit a Travel Risk assessment form in plenty of time (minimum of 6-8 weeks) before your journey. Once you have returned your completed form, please allow 5 working days for the travel nurses to review. After the 5 working days, please call back so we can book you an appointment based on the nurses’ recommendations.

We are also a Yellow Fever centre.

Travel Risk Assessment Form
DD/MM/YYYY
Gender
Please let us know your preferred contact number in case we need to contact you.

PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW

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
Accommodation

PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY

Are you fit and well today?
Any allergies including food, latex, 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 or kidney problems?
HIV / AIDS?
Immune system condition?
Mental health issues (including anxiety, depression)?
Neurological (nervous system) illness?
Rheumatology (joint) conditions?
Spleen problems?
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

Sending