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 be aware that we require at least 6 weeks notice before you travel to allow time for your vaccinations.

Date of Birth Required
Gender Required


Trip Details

Departure date Required


Trip Description

Purpose of trip Required
Type of trip Required
Accommodation Required
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?