Travel Clinic Assessment

When travelling abroad it is advised that you consult your travel nurse to get important advice and information that will help to keep you safe during your travel. Please complete and submit the Travel Assessment Form 4-6 weeks before you travel and arrange an appointment to be seen by the Travel Nurse.

Name*

First Last

Date of birth*

Phone

Email*

Home Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Name of GP

Gender*

Male
Female

What date will you be leaving for your holiday?*

What date will you be returning from your holiday?*

How many days will your holiday be?*

What countries will you be visiting?*

Are you travelling alone?*

Yes
No

What type of accommodation will you be staying in during the length of your holiday?*

What activities will you be involved in during your holiday?*

Have you got any past or current medical conditions?*

No
Yes

Please provide details below:

Are you currently taking any medications?*

No
Yes

Please provide details below:

Have you got any allergies?*

No
Yes
No sure

Please provide details below:

If you have had vaccinations in the past that you have had a reaction to, please provide details below.

Please include date the vaccination was given; the name of vaccination and the type of reaction you experienced.

Do you normally feel faint after having any injections?*

Yes
No
Sometimes

Is there any family history of Epilepsy?*

Yes
No
Don't know

Do you suffer from any form of Mental Illness?*

Yes
No
Not sure

Have you undergone any of the treatments listed below?*

● Radiotherapy ● Chemotherapy ● Steroid treatment

Yes
No

Please give details below, including details and duration of treatment

It is advised that you take out travel Insurance for your duration of your travel. If you have taken out travel insurance, have you informed the insurance company of any medical condition that you may have?*

Yes
No
Not yet

Have you taken Malaria tablets before?

Yes
No

Please provide details below.

Have you previously been given any of the vaccinations listed below?*

If you have further questions or concerns that you would like to discuss with your travel nurse, please give details below.

I confirm that the information provided is accurate to the best of my knowledge*

Confirm

Phone

This field is for validation purposes and should be left unchanged.

Travel Clinic Information & Assessment

TRAVEL CLINIC INFORMATION & ASSESSMENT FORM