Please give details of country to be visited, length of stay, and how remote you'll be from medical help

Type of trip (Select all applicable) BusinessPleasureOther

Holiday type (Select all applicable) PackageSelf organisedBackpackingCampingCruise shipTrekking

Accommodation (Select all applicable) HotelRelatives / family homeOther

Travelling (Select all applicable) AloneWith Family/ FriendIn a group

Staying in area which is... (Select all applicable) UrbanRuralAltitude

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? YesNoDon't know

Does having an injection make you feel faint? YesNoDon't know

Do you or any close family members have epilepsy? YesNoDon't know

Do you have any history or mental illness including depression or anxiety? YesNoDon't know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment? YesNoDon't know

Women only: Are you pregnant or planning pregnancy or breast feeding? YesNoDon't know

Have you taken out travel insurance and if you have a medical condition, have you informed the insurance company about this? YesNoDon't know

Please write below any further information which may be relevant

Have you ever had any of the following vaccinations / malaria tablets? (Select all applicable) TetanusPolioDiphtheriaTyphoidHepatitis AHepatitis BMeningitisYellow FeverInfluenzaRabiesJap B EncephTick BorneOther / Malaria tablets

Patient Signature

Monday:	9:00am – 6.00pm
Tuesday:	9:00 am – 6.00 pm
Wednesday:	9:00 am – 6.00 pm
Thursday:	9:00 am – 6.00 pm
Friday:	9:00 am – 6.00 pm
Saturday:	Closed
Sunday:	Closed

Risk Assessment Travel Form