Travel Risk Assessment

Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. Please submit your form at least 6 weeks before your departure date. If completed with inadequate time your form may not be processed. 

  • Your Details

    Date of Birth
    For example, 15 3 1984
    Gender

  • Trip Details

    Departure Date
    For example, 15 3 1984
    Have you taken out travel insurance?
    Do you plan to travel abroad again in the future?

  • Trip Description

    Purpose of Trip (optional)
    Type of Trip (tick all that apply) (optional)
    Travelling (optional)

  • Personal Medical History

    Are you fit and well today? (optional)
    Do you have a tendency to faint with injections? (optional)
    Have you recently undergone radiotherapy, chemotherapy or organ transplant? (optional)
    Do you have Anaemia? (optional)
    Do you have bleeding or clotting disorders including a history of DVT? (optional)
    Do you have Heart Disease? e.g Angina or High Blood Pressure? (optional)
    Do you have a physical disability? (optional)
    Do you have Diabetes? (optional)
    Do you have Epilepsy or seizures? (optional)
    Do you have Gastrointestinal (Stomach) complaints? (optional)
    Do you have any Liver/Kidney problems? (optional)
    Do you have HIV or AIDS? (optional)
    Do you have a mental health condition including Anxiety or Depression? (optional)
    Do you have a neurological illness? (optional)
    Do you have a respiratory (Lung) disease? (optional)
    Do you have any rheumatology (Joint) conditions (optional)
    Do you have any Spleen problems? (optional)

  • Women only

    Are you pregnant? (optional)
    Are you breast feeding? (optional)
    Are you planning pregnancy whilst away? (optional)

  • Current Medications

  • Vaccination History

    Have you ever had any of the following vaccinations / tablets (optional)

  • Additional Information

    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
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Page last reviewed: 25 August 2026
Page created: 24 March 2025