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. Find out more about our travel vaccination service…

Please Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Travel Risk Assessment

Travel Risk Assessment

If you are human, leave this field blank.

Section

Date of Departure:

Please use this date format: DD/MM/YYYY.

Total length of trip:

Have you taken out travel insurance for this trip?

Yes

No

Do you plan to travel abroad again in the future?

Yes

No

Country to be visited:

Exact location or region:

City or rural:

Will you be in transit anywhere?

Type of travel and purpose of trip - please tick all that apply

Holiday

Staying in a hotel

Backpacking

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

Are you fit and well today?

Yes

No

Any allergies including food, latex or medication?

Yes

No

What are you allergic to? *

Severe reaction to a vaccine before?

Yes

No

Tendency to faint with injections?

Yes

No

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

Yes

No

Which surgical operation(s) have you had?

Recent chemotherapy / radiotherapy / organ transplant?

Yes

No

Anaemia / bleeding / clotting disorders (including history of DVT)?

Yes

No

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

Yes

No

Diabetes?

Yes

No

Disability?

Yes

No

Epilepsy / seizures?

Yes

No

Gastrointestinal (stomach) complaints?

Yes

No

Liver and kidney problems?

Yes

No

HIV / AIDS

Yes

No

Immune system condition?

Yes

No

Mental health issues (including anxiety, depression)?

Yes

No

Neurological (nervous system) illness?

Yes

No

Respiratory (lung) disease?

Yes

No

Rheumatology (joint) conditions?

Yes

No

Any other conditions?

Yes

No

Women only

Are you pregnant?

Yes

No

Are you breast feeding?

Yes

No

Are you planning pregnancy while away?

Yes

No

Comments / Medications:

Please supply information on any vaccines or malaria tablets taken in the past

Tetanus / Polio / Diptheria:

MMR:

Influenza:

Typhoid:

BCG:

Hepatitis A:

Pneumococcal:

Hepatitis B:

Meningitis:

Malaria Tablets:

Rabies:

Japanese Encephalitis:

Tick Borne Encephalitis:

Yellow Fever:

Other:

Please visit the NathNac travel advise website before submitting this form so that you are aware of the travel advice and vaccine requirements for your destination: NaTHNaC - Country List (www.travelhealthpro.org.uk)

*

I confirm that I have visited the Nathnac website and read the relevant recommendations for my travel