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.

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? *
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 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.

Vaccinations

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