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Travel Risk Assessment Form

Please fill out the form below, before you visit us for your travel health & vaccines appointment.

    Please supply information about your trip in the sections below

    Country to be Visited
    Country to be Visited
    YesNo
    CarTrain
    BusPlane
    BoatOther
    HolidayStaying in hotelBackpackingBusiness tripCruise ship trip
    Camping/hostelsExpatriateSafariAdventureVolunteer work
    PilgrimageDivingHealthcare workerMedical tourismVisiting friends/family

    Please supply details of your personal medical history