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

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

DD/MM/YYYY

Gender

Male

Female

Email Address: *

Phone Number:

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

Date of Departure:

Total length of trip:

Country to be visited

Exact location or region

City or rural

Length of stay

Have you taken out travel insurance for this trip?

Yes

No

Do you plan to travel abroad again in the future?

Yes

No

Type of travel and purpose of trip

Holiday

Business trip

Expatriate

Volunteer worker

Healthcare worker

Staying in hotel

Cruise ship trip

Safari

Pilgrimage

Medical tourism

Backpacking

Camping / hostels

Adventure

Diving

Visiting friends / family

Accommodation

Hotel

Camping

Hostels

Friends/Family

PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY

Are you fit and well today?

Yes

No

Why?

Any allergies including food, latex, medication?

Yes

No

Details:

Severe reaction to a vaccine before?

Yes

No

Details:

Tendency to faint with injections?

Yes

No

Details:

Any surgical operations in the past, including e.g. your spleen or thymus gland removed?

Yes

No

Details:

Recent chemotherapy / radiotherapy / organ transplant?

Yes

No

Details:

Anaemia?

Yes

No

Details:

Bleeding / clotting disorders (including history of DVT)?

Yes

No

Details:

Heart disease (e.g. angina, high blood pressure)?

Yes

No

Details:

Diabetes?

Yes

No

Details:

Disability?

Yes

No

Details:

Epilepsy / seizures?

Yes

No

Details:

Gastrointestinal (stomach) complaints?

Yes

No

Details:

Liver and or kidney problems?

Yes

No

Details:

HIV / AIDS?

Yes

No

Details:

Immune system condition?

Yes

No

Details:

Mental health issues (including anxiety, depression)?

Yes

No

Details:

Neurological (nervous system) illness?

Yes

No

Details:

Rheumatology (joint) conditions?

Yes

No

Details:

Spleen problems?

Yes

No

Details:

Any other conditions?

Yes

No

Details:

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)? Please list:

Women only

Are you pregnant?

Yes

No

Details:

Are you breast feeding?

Yes

No

Details:

Are you planning pregnancy while away?

Yes

No

Details:

PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST

Tetanus/polio/diptheria

Typhoid

Cholera

Rabies

Yellow fever

MMR

Hepatitis A

Hepatitis B

Japanese Encephalitis

BCG

Influenza

Pneumococcal

Meningitis

Tick Borne Encephalitis

Malaria tablets

Other

ANY ADDITIONAL INFORMATION