Travel Risk Assessment

If you are a registered patient with us and 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 telephone 0118 9713252 to find out when you should make an appointment and what immunisations or malaria prophylaxis is advised.

Travel Risk Assessment

Travel Risk Assessment

Full Name *

Date of Birth *

Please use this date format: DD/MM/YYYY.

Email Address *

Phone Number

Date of Departure

Please use this format: DD/MM/YYYY

Please list all the countries (including exact location/region) you are visiting, including total length of each stay.

Please state any stopovers for more than 12 hours

Total length of trip

Type and purpose of trip

Do you plan to travel abroad again in the future?

Yes

No

Have you taken out insurance for this trip?

Yes

No

Are you fit and well?

Yes

No

Are you pregnant or planning to conceive?

Yes

No

Are you allergic to anything?

Yes

No

Please list your known allergies

Have you had a reaction to a vaccine before?

Yes

No

Are you immunocompromised?

Yes

No

Do you have a spleen?

Yes

No

Are you undergoing any treatment for cancer or waiting for surgery?

Yes

No

Please give details of any further details about your health we should be aware of:

*

I confirm that the information provided is accurate to the best of my knowledge.

If you are human, leave this field blank.