Travel Risk Assessment
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
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:
Including diabetes, heart or lung conditions

Women only

Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised?

Further Information

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, steroid treatment or Organ Transplant?
Have you had any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Are you fit and well today?
Do you suffer from bleeding /clotting disorders (including history of DVT)?
Do you suffer from Heart disease (e.g. angina, high blood pressure)

If you suffer with any of the following, please specify in the box below: 

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.


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

Please state which year you had the vaccination(s):