Travel Vaccination Risk Assessment

To be completed by travellers prior to vaccination appointment.

Your Details

County of Origin *

Gender *

Male

Female

Your name *

Date of Birth *

Contact Details

Please provide whichever contact details you have.

E-mail Address

Home Telephone Number

Mobile Number

Please supply information about your trip

Date of departure *

Total length of trip *

Have you taken out travel insurance for this trip? *

Yes No

Do you plan to travel abroad again in the future? *

Yes No

Country Details (#1)

Enter information about the first country to be visited.

Country *

Exact location or region *

Type of area *

City

Rural

Length of stay *

Country Details (#2)

Enter information about the second country to be visited on your trip. Please skip this section if it is not applicable.

Country

Exact location or region

Type of area

City

Rural

Length of stay

Country Details (#3)

Enter information about the third country to be visited on your trip. Please skip this section if it is not applicable.

Country

Exact location or region

Type of area

City

Rural

Length of stay

Please supply details of your personal medical history

Please supply details of your personal medical history (WOMEN ONLY)

Are you pregnant?

Yes No

Are you breast feeding?

Yes No

Are you planning pregnancy while away?

Yes No

Have you undergone FGM, been cut or circumcised?

Yes No

If you have answered yes to any of the previous questions in this section, provide any details below

Vaccine and malaria information

Additional information

If you have any additional information that you feel is relevant to your travel assessment, please provide it below

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Travel Vaccination Risk Assessment

Travel Vaccination Risk Assessment

Further Information