Travel Risk Assessment

This form is to be submitted 3 days before your travel appointment.

Travel Risk Assessment

Travel Risk Assessment

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Planned activities:
Type of trip:
Staying in area which is:

Including diabetes, heart or lung conditions
Are you fit and well today?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Have you had any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
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 a disability?
Do you or any close family members have epilepsy?
Do you have gastrointestinal (stomach) complaints?
Do you have liver and or kidney problems?
Do you have HIV/AIDS?
Do you have an immune system condition?
Do you have any history or mental illness including depression or anxiety?
Do you have a neurological (nervous system) illness?
Do you have a respiratory (lung) disease?
Do you have rheumatology (joint) conditions?
Do you have spleen problems?
Do you have any other conditions?
Are you pregnant or planning pregnancy or breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Do you plan to travel abroad again in the future?

Who is the lead traveller for your group?

Do you consent to your previous travel immunisation details being shared with the ‘Lead Traveller’ of your group?

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

Please state which year you had the vaccination(s):

Please bring with you any information regarding past travel vaccinations you may have.

For any further travel information prior to your travel appointment, please visit