Travel Risk Assessment

If you are travelling abroad and require travel advice, please make sure you contact us more than 8 weeks before travel. Please complete this assessment form, and we will contact you to arrange your initial telephone appointment with a travel nurse.

Allowing more than 8 weeks before travel will give us plenty of time to arrange a telephone appointment with our nurse and time to arrange any necessary vaccinations.

If you are submitting this form within 8 weeks of travel, you will be asked to locate a Travel Clinic for advice and vaccinations

Travel Risk Assessment

Travel Risk Assessment

Sex:
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Including diabetes, heart or lung conditions
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Have you ever had any of the following vaccinations / malaria tablets?

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

*