Travel Risk Assessment


Please use this date format: DD/MM/YYYY
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip:

Medical history

Are you fit and well today?
Do you have any allergies including food, latex, medication?
Have you ever had a severe reaction to a vaccine before?
Does having an injection make you feel faint?
Have you had any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Have you had any recent chemotherapy/radiotherapy/organ transplants?
Do you have anaemia?
Do you have bleeding/clotting disorders (including history of DVT)?
Do you have heart disease (e.g. angina, high blood pressure)?
Do you have diabetes?
Do you have a disability?
Do you have epilepsy/seizures?
Do you have gastrointestinal (stomach) complaints?
Do you have liver and or kidney problems?
Do you have HIV/AIDS?
Do you have an immune system condition?
Do you have mental health issues (including anxiety, depression)?
Do you have a neurological (nervous system) illness?
Do you have respiratory (lung) disease?
Do you have rheumatology (joint) conditions?
Do you have spleen problems?
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised?
Have you ever had any of the following vaccinations / malaria tablets?

Please state which year you had the vaccination(s):