Travel Assessment

We offer full travel advice and immunisation service. If you are traveling abroad please complete and submit the travel form in plenty of time (we recommend 6-8 weeks) before your journey.

Travel Risk Assessment Form

Travel Risk Assessment V2

YOUR DETAILS

Name
DD slash MM slash YYYY
Gender

TRIP DETAILS

DD slash MM slash YYYY

TRIP DESCRIPTION

Purpose of Trip
Type of Trip
Accommodation
Travelling
Location Type
Activity type

PERSONAL MEDICAL HISTORY

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

VACCINATION HISTORY

Have you ever had any of the following vaccinations / tablets and if so, when?
Consent