Travel Risk Assessment Form
To be completed prior to appointment
< ontact details>
Date of birth
Travel Information (please tick all that apply)
□ Business trip
□ Expatriate □ Cruise ship
Accommodation □ Hotel
City or Rural
□ Volunteer work
□ Healthcare worker
Length of Stay
□ Visiting friends/family
Are you fit and well today
Severe reaction to a vaccine before
Tendency to faint with injections
Any surgical operations in the past, including e.g. your
spleen or thymus gland removed
Recent chemotherapy/radiotherapy/organ transplant
Bleeding /clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Gastrointestinal (stomach) complaints
Liver and or kidney problems
Immune system condition
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Any other conditions?
Are you pregnant?
Page 1 of 2
Are you breast feeding?
Are you planning pregnancy while away?
Information on any vaccines or malaria tablets taken in the past
Please amend this as necessary (include food, latex and medication)
<Allergies & Sensitivities>
Please amend this as necessary (include prescribed, purchased or contraceptive pill)
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Page 2 of 2
<Patient name>, <Date of birth>, <NHS number>