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.

Travel Risk Assessment New
Please use this date format: DD/MM/YYYY.
Can we contact you by email?
Can we contact you by text message?
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Type of trip:
Holiday type:
Staying in area which is:
Planned activities:
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Have you ever had any of the following vaccinations / malaria tablets?
Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

Please note that the details you give will be used to update your medical records.

For Official Use

Travel risk assessment performed

Travel vaccines recommended for this trip

Hepatitus A
Hepatitus B
Meningitus ACWY
Yellow Fever
Japanese B Encephalitis
Other .....................

Travel advice and leaflets given as per travel protocol

Malaria prevention advice and malaria chemoprophylaxis

Further information

Authorisation for Patient Specific Direction (PSD) Use