Travel Risk Assessment Travel risk assessment If you are travelling abroad please make sure you contact us in plenty of time to arrange 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 your appointment. Full name Email address Phone number Gender Male Female Other If other, please specify Security question (used to identify you) In which month did you last see a doctor/nurse at this surgery? Do you take any prescribed medicines? Can you tell me what they are? Have you had an operation in hospital? Can you remember when and what it was for? Security answer Please give details of country to be visited, length of stay, and how remote you'll be from medical help: Holiday type Package Self-organised Backpacking Camping Cruise ship Trekking Other (please specify Type of trip Business Pleasure Other Accommodation Hotel Relatives/family home Other Travelling Alone With family/friend In a group Other Staying in an area which is: Urban Rural Altitude Other Planned activities: Safari Adventure Other If you selected other in the above options, please provide further details here List any recent or past medical history of note: Including diabetes, heart or lung conditions List any current or repeat medications: List any allergies: 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 write below any further information which may be relevant: Have you ever had any of the following vaccinations / malaria tablets? Tetanus Typhoid Meningitis Rabies Other/Malaria tablets Polio Hepatits A Yellow fever Jab B Enceph Diptheria Hepatitis B Influenza Tick-borne enceph (TBE) Signed This form is automatically dated upon submission. Privacy statement This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data. Data concent Data concent