Travel Risk Assessment Online

Travel Questionaire

Please complete the form below to get more information about what travel immunisations you require.

If you are travelling abroad, please contact us as early as possible to discuss your vaccinations normally three months before you travel .You will need to complete a travel risk assessment form for each member of your party travelling with you. The nurse will use the information in the form to prepare for your appointment.
Once our travel nurses have assessed your form(s) , they will be in contact to arrange an initial telephone consultation to discuss all your travel requirements. They will then arrange for your face to face vaccination appointment or a vaccine course to be commenced. As some vaccinations require more than one injection, please be aware you will need to have follow-up appointments.
Details of travel vaccination fees can be found on our website.
If we receive the completed form less than 4 weeks prior to travel we will be unable to see patients. This is because:

  • There is insufficient time to plan and arrange appointments
  • Possible insufficient time for the vaccines to be effective
  • Insufficient time for vaccine courses to be completed or the ordering of vaccinations
Title *
Address *


Further Information

Purpose of your trip *
Holiday Type *
Accommodation *
Travelling with:
Planned Activities

Personal Medical History

Please provide details of your personal medical history and supply details, if necessary
Are you fit for travel? *
Have you had a severe reaction to a vaccine before
Any surgical operation in the past, including spleen or thymus gland removed
Any recent chemotherapy / radiotherapy / organ transplant
Bleeding / clotting disorders, including a history of DVT
Heart disease – eg angina, high blood pressure
Epilepsy /seizures
Liver or kidney problems
Immune system condition
Mental health issues, including anxiety or depression
Rheumatology (joint) conditions
Spleen problems
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?

Women Only

Are you or could you be pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Are you currently taking a n medication (including prescribed, purchased or a contraceptive pill?)

Vaccination history

Have you ever had any of the followingvaccinations / malaria tablets, and if so, when?

Malaria tablets
Hepatitis A
Yellow fever
Jap 8 enceph
Hepatitis B
Tick borne