Travel Assessment Form Travel Assessment Form If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. 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 Assessment Form If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.Name* First Last Date of Birth* GenderMaleFemaleOtherDate of Departure* Return Date* Please give details of country to be visited, length of stay, and how remote you'll be from medical helpType of tripBusinessPleasure OtherOtherHoliday typePackageSelf organisedBackpackingCampingCruise shipTrekkingAccommodationHotelRelatives / family homeOtherTravellingAloneWith family / friendIn a groupStaying in area which is...UrbanRuralAltitudePlanned activitiesSafariAdventureOtherDo you have any recent or past medical history of note? (including diabetes, heart or lung conditions)List any current or repeat medicationsDo you have any allergies for example to eggs, antibiotics, nuts?If yes please list allHave you ever had a serious reaction to a vaccine given to you before?YesNoDon't KnowDoes having an injection make you feel faint?YesNoDon't KnowDo you or any close family members have epilepsy?YesNoDon't KnowDo you have any history or mental illness including depression or anxiety?YesNoDon't KnowHave you recently undergone radiotherapy, chemotherapy or steroid treatment?YesNoDon't KnowHave you taken out travel insurance and if you have a medical condition, informed the insurance company about this?YesNoDon't KnowPlease write below any further information which may be relevantHave you ever had any of the following vaccinations / malaria tablets? Tetanus Polio Diptheria Typhoid Hepatitis A Hepatitis B Meningitis Yellow Fever Influenza Rabies Jap B Enceph Tick Borne Other / Malaria tablets Please tick this box to confirm that you understand that you are responsible for booking the appropriate appointment in the travel clinic. Signed*Date* 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.