Travel Questionnaire

Travel Questionnaire

Travel Risk Assessment Form

Please complete the form below to get more information about what travel immunisations you require. Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Please try to give us prior notice (preferably 6 weeks).
Date of Birth

Please supply information about your trip in the sections below

UK Departure Date
Please enter a number from 0 to 99999.
Further Information
Type of travel and purpose of trip – Please tick all that apply

Please provide deatils of your personal medical history

Are you fit and well today?
Do you have any allergies including food, Latex, Medication?
Severe reaction to a vaccine before?
Tendency to faint with Injections?
Any Surgical Procedures in the past, including eg. your Spleen or Thymus Gland Removed
Recent chemotherapy/ radiotherapy/ Organ transplant?
Bleeding/ Clotting disorders (Including History of DVT)
Heart Disease (e.g.Angina, High Blood Pressure)
Epilepsy/ Seizures
Gastrointestinal (Stomach) Complaints
Liver and or Kidney Problems
Immune System Condition
Mental Health issues (including anxiety, depression)
Mental Health issues (including anxiety, depression)
Neurological (Nervous System) Illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen Problems

Women Only

Are you Preganant?
Are you Breast feeding?
Are you planning pregnancy while away?
Are you currently taking any medication (including prescribed, purchased or a contreceptive pill?)

Please supply information on any Vaccines or Malaria tablets taken in the past