Travel Risk Assessment Form

To be completed 6-8 weeks prior to departure. If you are travelling before 6 weeks, please contact a private travel clinic (such as Boots/Asda)

Patient Details

Required
Date of Birth: Required
Required

Travel Itinerary

Country 1

Required
Required
Required

Country 2

Travel Information

Type of holiday:
Accommodation:
Activities:

Medical History

Please check all that apply:

Vaccination History

Please tick all that apply:

Allergy Information

Current Medication

Further information

Required