Travel Risk Assessment

If you are travelling abroad please make sure you are within 6 weeks of travel for 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 you are contacted.

For more information please use the following link: www.fitfortravel.nhs.uk.

Travel Risk Assessment

Sex: *
Please use this date format: DD/MM/YYYY
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?

Type of Travel / Purpose of Trip

Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:

Personal Medical History

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 recently undergone radiotherapy, chemotherapy or steroid treatment?
Anaemia:
Bleeding / clotting disorders (including history of DVT):
Heart disease (e.g. angina, high blood pressure):
Diabetes:
Disability:
Epilepsy/seizures:
Gastrointestinal (stomach) complaints:
Liver and or kidney problems:
HIV/AIDS:
Immune system condition:
Mental health issues including depression or anxiety:
Neurological (nervous system) illness:
Respiratory (lung) disease:
Rheumatology (joint) conditions:
Spleen problems:

Vaccinations / Malaria Tablets

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

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

*