Travel Risk Assessment Form Surname First name Address Email Address Date of Birth Contact Telephone Number Please supply information about your trip in the sections below Stop Over? Yes No Country of Stop Over Length of Stay Country Exact Location/Region Length of Stay City or rural Country Exact Location/Region Length of Stay City or rural Country Exact Location/Region Length of Stay City or rural Type of travel and purpose of trip, tick all that apply Hotel Sport/adventure/safari/diving Business Private House Relaxation/city sightseeing Healthcare worker Camping/hostel Back packing/expedition Medical tourism Cruise Visiting family and friends Pilgrimage Date of departure Return Date Please supply details of your personal medical history Do you have any of the following: Blood clotting disorders (history of DVT/PE) Kidney/Liver disease Heart Disease (angina/High blood pressure) Insulin Diabetes Recent chemotherapy/ radiotherapy/ organ transplant Epilepsy/seizures Asthma/COPD Respiratory disease Operations to remove spleen/thymus Immune system deficiency HIV/AIDS Disability Cerebrovascular disease Mental Health Issues Neurological illness Any other conditions Please state: Are you pregnant? Yes No If yes please provide details Are you planning a pregnancy? Yes No If yes please provide details: Are you breast feeding? Yes No Have you had a severe reaction to a vaccine before? Yes No If yes please provide details: Please state any allergies including food/latex/medication: Tendency to faint with injections? Yes No Have you taken out travel medical insurance for this trip? Yes No Do you plan to travel abroad in the near future? Yes No History of previous vaccinations Cholera Yes No Date if known Diphtheria/ Tetanus/ Polio Yes No Date if known Japanese Encephalitis Yes No 1st vaccination date if known 2nd vaccination date if known Hepatitis A Yes No 1st vaccination date if known 2nd vaccination date if known Hepatitis B Yes No 1st vaccination date if known 2nd vaccination date if known 3rd vaccination date if known Typhoid Yes No Date if known Yellow Fever Yes No Date if known Rabies Yes No 1st vaccination date if known 2nd vaccination date if known 3rd vaccination date if known MMR Yes No 1st vaccination date if known 2nd vaccination date if known BCG Yes No Date if known Meningitis Yes No Date if known Please list all the tablets and medicines that you are presently taking regularly Medication Dose Medical Condition Medication Dose Medical Condition Medication Dose Medical Condition Medication Dose Medical Condition Medication Dose Medical Condition Medication Dose Medical Condition Any additional information: Signature of patient Date Please note not all travel vaccines are available on the NHS
