Travel Risk Assessment

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All questions marked with a * are mandatory

Ideally we would prefer that this form is completed by the traveller prior to the appointment.

  • To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.
  • We also may need to order the vaccinations that you require.
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Personal Details
Gender: *
Please double check you've entered the correct email address
May be used to identify you
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Please supply information about your trip in the sections below
1. City or rural: *
2. City or rural:
3. City or rural:
Type of travel and purpose of trip (Please tick all that apply): *
Have you taken out travel insurance for this trip?: *
Do you plan to travel abroad again in the future?: *
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Please supply details of your Personal Medical History
Are you fit and well today: *
Any allergies including food, latex, medication: *
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?: *
Tendency to faint with injections: *
Any surgical operations in the past, including e.g. openheart surgery, spleen or thymus gland removal?: *
Recent chemotherapy/radiotherapy/organ transplant: *
Anaemia: *
Bleeding /clotting disorders (including history of DVT): *
Heart disease (e.g. angina, high blood pressure): *
Diabetes: *
Additional needs and/or disability: *
Epilepsy/seizures (or in a first degree relative?) : *
Gastrointestinal (stomach) complaints: *
Liver and/or kidney problems: *
HIV/AIDS: *
Immune system condition e.g. blood cancer: *
Mental health issues (including anxiety, depression): *
Neurological (nervous system) illness: *
Respiratory (lung) disease: *
Rheumatology (joint) conditions: *
Spleen problems: *
Any other conditions?: *
Are you or your partner pregnant or planning a pregnancy?: *
Are you breast feeding (if applicable) :
Have you or anyone in your family undergone FGM / been cut / circumcised: *
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Please supply information on any vaccines or malaria tablets taken in the past
Vaccines & Malaria tablets: *
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Signed & Dated

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