Travel Risk Assessment

Section

Sex:
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Including diabetes, heart or lung conditions
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
For more information about travel insurance, please read the guidance on the Travel Health Pro website.
Have you ever had any of the following vaccinations / malaria tablets?

Please state which year you had the vaccination(s):