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 12 weeks notice before you travel to allow time for your vaccinations.

  • 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)
    Additional needs and/or disability (optional)
    Type of Trip (optional)
    Accommodation (optional)
    Travelling (optional)
    Location Type (optional)
    Activity type (optional)

  • Personal Medical History

    Are you fit and well today? (optional)
    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)
    Are you pregnant, planning pregnancy or breast feeding? (optional)
    Spleen problems (optional)
    Rheumatology (joint) conditions (optional)
    Neurological (nervous system) illness (optional)
    Immune system condition e.g. blood cancer (optional)
    HIV/AIDS (optional)
    Have you or anyone in your family undergone FGM/been cut/circumcised? (optional)
    Have you taken out travel insurance? (optional)
    If you have a medical condition, have you told your insurance company about it? (optional)

  • Vaccination History

    Have you ever had any of the following vaccinations / tablets and if so, when? (optional)
    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
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Page last reviewed: 14 October 2024
Page created: 15 October 2026