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.

Required field(s) are indicated by *
Travel Risk Assessment

Travel Risk Assessment

About you

As it appears on your passport.

As it appears on your passport.

The one used to register with your GP.

Your date of birth is required to verify your identity.

As on your medical record.
This phone number will be used for all correspondence relating to this request.

This email address will be used for all correspondence relating to this request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please continue completing the form below
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?
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