Travel Risk Assessment

If you’re planning to travel abroad, please get in touch with us at least 8 weeks before your departure to arrange any necessary vaccinations. In order to assist the travel nurses in assessing your travel requirements, it’s vital that they have received your risk assessment form prior to your appointment.

Travel Risk Assessment

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
Staying in area which is:
Planned activities:
Including diabetes, heart or lung conditions
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 or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Have you ever had any of the following vaccinations / malaria tablets?

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


For practice use only

Travel advice and leaflets given as per travel protocol:
Malaria prevention advice and malaria chemoprophylaxis: