Travel Risk Assessment Form 2024

To help us offer the most appropriate advice, please complete and return this questionnaire at least 8 weeks before you travel.

Any questionnaires submitted less than 8 weeks in advance will be not be accepted by the travel team and you will be advised to contact a travel clinic.

Once completed, the submitted form will be sent to one of our travel nurses who will decided what consultation is required and ask a member of our admin team to contact you to arrange an appointment. Please note there may be a small delay between your submission and the nurses response.

Last Updated: 15/10/2024

  • Your Details

    Date of Birth:
    For example, 15 3 1984
    Gender:

  • Trip Details

    Please supply information about your trip in the sections below

    Date of Departure:
    For example, 15 3 1984
    Have you taken out travel insurance for this trip?
    Do you plan to travel abroad again in the future?

  • Type of Travel and Purpose of the Trip

    Please tick all that apply:

  • Personal Medical History

    Please supply details of your personal medical history

    Are you fit and well today?
    Do you have any allergies including food, latex, medication?
    Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?
    Do you have a tendency to faint with injections?
    Have you had any surgical operations in the past, including open-heart surgery, spleen or thymus gland removal?
    Have you had any recent chemotherapy / radiotherapy / organ transplant?
    Do you have anaemia?
    Do you have any bleeding / clotting disorders (including history of DVT)?
    Do you have heart disease (e.g. angina, high blood pressure)?
    Do you have diabetes?
    Do you have any additional needs and/or disability?
    Do you or a first degree relative have epilepsy/seizures?
    Do you have gastrointestinal (stomach) complaints?
    Do you have liver or kidney problems?
    Do you have HIV / AIDS?
    Do you have an immune system condition e.g. blood cancer?
    Do you have mental health issues (including anxiety and/or depression)?
    Do you have a neurological (nervous system) illness?
    Do you have a respiratory (lung) disease?
    Do you have a rheumatology (joint) condition?
    Do you have spleen problems?
    Are you or your partner pregnant or planning a pregnancy?
    Are you breast feeding (if applicable)? (optional)
    Have you or anyone in your family undergone FGM / been cut / circumcised?

  • Vaccination History

    Please supply information on any vaccines or malaria tablets taken in the past

    Have you ever had any of the following vaccinations / tablets?
    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 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.
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