Travel Risk Assessment

Before booking a Travel Clinic, we kindly ask that you input and submit your details using the following Travel Risk Assessment form:






Contact Details

Details of traveller - fields which include '*' are required:

Contact Name*

Email Address*

Contact Number*

Gender

Date of Birth

Country of Origin

 
 

Trip Details

Details of full trip:

Date of Departure

Length of Trip

 
 

Country Details

Details of country(s) visiting:

Name of Country(s)

Exact Location(s)

Length of Stay

City / Rural

Do you have Travel Insurance?

Do you plan to travel again?

 
 

Purpose of Trip

Type of holiday and/or purpose of the trip - please tick all that apply:

Adventure

Backpacking

Business

Camping

Cruise

Diving

Expatriate

Healthcare

Holiday

Hostels

Hotel

Pilgrimage

Safari

Volunteer

 
 
 

Medical History

Details of the travellers personal medical history:

Are you taking any medication (prescribed or over the counter)?

 

Do you have any allergies (including food, latex or medication)?

 

Do you tend to faint with injections?

 

Have you had any surgical operations in the past, including your spleen or thymus gland removed?

 

Have you recently had chemotherapy, radio therapy or an organ transplant?

 

Women Only: Are you currently pregnant or breast feeding?

 

Women Only: Are you planning a pregnancy in the next 3 months whilst away?

 
 
 

Past Vaccines / Medication

Details of the travellers past vaccines / medication - please tick all that apply:

BCG

Cholera

Hepatitis A

Influenza

Japanese Encephalitis

Malaria Tablets

Meningitis

MMR

Pneumococcal

Rabies

Tetanus / Polio / Diphtheria

Tick Borne Encephalitis

Typhoid

Yellow Fever

 

Additional Information

 

 

Please Note: A member of the Support Team will contact you within 2 working days following receipt of your assessment.