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Travel Risk Assessment Form

If you are travelling abroad please complete and submit this travel form in plenty of time (we recommend 6-8 weeks) before your journey. 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

First Name *

Last Name *

Email *

Enter Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Gender *

Male

Female

Date of Departure *

Please use format day/month/year e.g. 12/05/2019

Date of Return *

Please use format day/month/year e.g. 12/05/2019

Country/Countries to be visited and length of stay *

How remote will you be from medical help? *

Type of trip *

Business

Pleasure

Other

Holiday type *

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

Accommodation *

Hotel

Relatives / family home

Other

Travelling *

Alone

With family/friends

In a group

Staying in area which is *

Urban

Rural

Altitude

Planned activities *

Safari

Adventure

Other

Do you have any allergies? (for example, to eggs, antibiotics, nuts) *

Have you ever had a serious reaction to a vaccine given to you before? *

Yes

No

Don't Know

Does having an injection make you feel faint? *

Yes

No

Don't Know

Do you or any close family members have epilepsy? *

Yes

No

Don't Know

Do you have any history or mental illness including depression or anxiety? *

Yes

No

Don't Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment? *

Yes

No

Don't Know

Do you have any medical history of mental illness? (including depression or anxiety) *

Yes

No

Don't Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment? *

Yes

No

Don't Know

Women Only: are you pregnant/ planning pregnancy/ breastfeeding?

I am pregnant

I am planning a pregnancy

I am breastfeeding

None of these apply to me

Have you ever had any of the following vaccinations / malaria tablets? *

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Other / Malaria tablets

NONE

Please supply dates and details of when you were given vaccinations / malaria tablets *

*

I consent to the vaccines being given and will discuss the risks and benefits of the vaccines recommended during my appointment with the travel nurse.

The Chaucer Surgery
Off School Walk
Attleborough
Nuneaton
Warwickshire
CV11 4UZ

Tel: 024 7638 3784
Email: [email protected]

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