Travel Risk Assessment

If you are travelling abroad please make sure you submit this form atleast 6 weeks before your departure date. If your departure date is sooner, we may not be able to complete the course of immunisations in time to guarantee full immunity and may therefore recommend another local private health clinic.

To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Travel Risk Assessment

Travel Risk Assessment

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Gender:
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Type of trip:
Holiday type:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Have you ever had any of the following vaccinations / malaria tablets?
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.
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