Travel Risk Assessment Form

Travel Risk Assessment Form

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 in plenty of time before your journey and that you book an appointment 8-10 weeks in advance.

  • Your Details

    Date of Birth
    For example, 15 3 1984
    Gender

  • Trip Details

    Departure Date
    For example, 15 3 1984

  • Trip Description

    Purpose of Trip (optional)
    Type of Trip (optional)
    Accommodation (optional)
    Travelling (optional)
    Type of Area (optional)
    Planned Activities (optional)

  • Personal Medical History

    Have you recently suffered from any infection (e.g. heavy cold, flu or high temperature)? (optional)
    Does having an injection cause you to feel faint? (optional)
    Do you or any close family members have epilepsy? (optional)
    Do you have any history of mental illness including depression or anxiety? (optional)
    Have you recently undergone radiotherapy, chemotherapy or steroid treatment? (optional)
    Have you taken out travel insurance? (optional)
    If you have a medical condition, have you informed your insurance company about it? (optional)
    Are you pregnant, planning pregnancy or breast feeding? (optional)

  • Vaccination History

    Have you ever had any of the following vaccinations / malaria tablets? (optional)
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Page last reviewed: 03 September 2025
Page created: 03 July 2023