Travel Risk Assessment

 
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All questions marked with a * are mandatory

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.
  • We also may need to order the vaccinations that you require.
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Personal Details
Please double check you've entered the correct email address
May be used to identify you
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Dates and Trip Details
1. City or rural: *
2. City or rural:
3. City or rural:
Type of travel and purpose of trip: *
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Please supply details of your Personal Medical History
Are you fit and well today: *
Any allergies including food, latex, medication: *
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: *
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 anxiety, depression): *
Neurological (nervous system) illness: *
Respiratory (lung) disease: *
Spleen problems: *
Any other conditions?: *
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Please supply details of your Personal Medical History (Women only)
Are you pregnant?: *
Are you breast feeding?: *
Are you planning pregnancy while away?: *
Have you undergone FGM / been cut / circumcised?: *
Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?: *
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Recommended NHS vaccinations
Tetanus/polio/diphtheria: *
Typhoid: *
Cholera: *
MMR: *
Hepatitis A: *
Malaria Tablets: *
Possible Private vaccinations
Hep B: *
Rabies: *
Japanese Encephalitis: *
Yellow Fever: *
Malaria Tablets: *
Tick-borne Enchephilitis: *
Other:
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Signed & Dated

Privacy Consent

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