Travel Assessment Form

Name*

First Last

Date of Birth*

Gender

Male
Female
Other

Date of Departure*

Return Date*

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

Type of trip

Business
Pleasure Other
Other

Holiday type

Accommodation

Hotel
Relatives / family home
Other

Travelling

Alone
With family / friend
In a group

Staying in area which is...

Urban
Rural
Altitude

Planned activities

Safari
Adventure
Other

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?

If yes please list all

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?

Please tick this box to confirm that you understand that you are responsible for booking the appropriate appointment in the travel clinic.

Signed*

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

Date*

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