TRAVEL RISK ASSESSMENT FORM
To be completed by traveller prior to appointment
Once you have sent your completed form back a member of our nursing team will contact you to arrange your appointment.
Name
Your country of origin
Date of birth
Gender
Email
Telephone Number
Mobile Number
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
1.
2.
3.
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 - PLEASE TICK ALL THAT APPLY
Holiday
Staying in hotel
Backpacking
Additional Information
Business trip
Cruise ship trip
Camping/hostels
Expatriate
Safari
Adventure
Volunteer work
Pilgrimage
Diving
Healthcare worker
Medical tourism
Visiting friends/family
PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY
YES/NO
DETAILS
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
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions?
Women Only
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised
Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?
PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST
Tetanus/polio/diphtheria
MMR
Influenza
Typhoid
Hepatits A
Pneumococcal
Cholera
Hepatits B
Meningitis
Rabies
Japanese encephalitis
Tick borne encephalitis
Yellow Fever
BCG
Other
Malaria Tablets
Any additional information
Submit Form