Travel Risk Assessment Form Travel Risk Assessment First Name * Last Name * Email * Enter Email Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * Gender * Male Female Date of Departure * Please use format day/month/year e.g. 12/05/2019 Date of Return * Please use format day/month/year e.g. 12/05/2019 Please give details of country to be visited, length of stay, and how remote you'll be from medical help * Type of trip * Business Pleasure Other Holiday type * Package Self organised Backpacking Camping Cruise ship Trekking Accommodation * Hotel Relatives / family home Other Travelling * Alone With family / friend In a group Staying in area which is * Urban Rural Altitude Planned activities * Safari Adventure Other Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions) * List any current or repeat medications * Do you have any allergies for example to eggs, antibiotics, nuts? * Have you ever had a serious reaction to a vaccine given to you before? * Yes No Don't Know Does having an injection make you feel faint? * Yes No Don't Know Do you or any close family members have epilepsy? * Yes No Don't Know Do you have any history or mental illness including depression or anxiety? * Yes No Don't Know Have you recently undergone radiotherapy, chemotherapy or steroid treatment? * Yes No Don't Know Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this? * Yes No Don't Know Please type below any further information which may be relevant: Have you ever had any of the following vaccinations / malaria tablets? * Tetanus Polio Diptheria Typhoid Hepatitis A Hepatitis B Meningitis Yellow Fever Influenza Rabies Jap B Enceph Tick Borne Other / Malaria tablets NONE Please supply dates and details of when you were given vaccinations / malaria tablets * * I have no reason to think that I might be pregnant. * I consent to the vaccines being given and will discuss the risks and benefits of the vaccines recommended during my appointment with the travel nurse. Terms & Conditions By using the forms contained here you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that because of the nature of the Internet we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of communicating with the practice. Personal information is not stored on this system but may be used to update your records with the practice. Send If you are human, leave this field blank.