Details completed on this form will be sent to the appropriate clinician.

Travel Clinic Form

TRAVEL RISK ASSESSMENT FORM - ideally to be completed by traveler prior to appointment.

Name
Name
First
Last

PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW

Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?

DESTINATION (Add more rows if you have multiple destinations planned)

City or Rural
plus1 Add minus1 Remove

TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT APPLY

PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY

Are you fit and well today
Any allergies including food, latex, medication
Severe reaction to a vaccine before
Tendency to faint with injections
Any surgical operations in the past, including e.g. your spleen or thymus gland removed
Recent chemotherapy/radiotherapy/organ transplant
Anaemia
Bleeding/Clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal (stomach) complaints
Liver and or kidney problems
HIV/AIDS
Immune system condition
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions?

WOMEN ONLY

Are you pregnant?
Are you breast feeding?
Are you planning on pregnancy while away?
Have you undergone FMG/been cut/circumcised

ARE YOU CURRENTLY TAKING ANY MEDICATION (including prescribed, purchased or a contraceptive pill)

PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST

ANY ADDITIONAL INFORMATION

Travel risk assessment form devised by Jane Chiodini © 2012 in conjunction with resources below.

  1. Chiodini J, Boyne L, Grieve S, Jordan A. (2007) Competencies: An Integrated Career and Competency Framework for Nurses in Travel
    Health Medicine. RCN, London. www.rcn.org.uk
  2. Field VK, Ford L, Hill DR, eds. (2010) Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK.

Form devised and created by Jane Chiodini © updated 2017

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