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 Form

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

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