Travel Risk Assessment

Step 1 of 2

Name  Required
Date of Birth  Required
Date of Departure  Required
Date of Return  Required
Type of trip  Required
Holiday type  Required
Accommodation  Required
Travelling  Required
Staying in area which is  Required
Planned activities  Required
Have you ever had a serious reaction to a vaccine given to you before?  Required
Does having an injection make you feel faint?  Required
Do you or any close family members have epilepsy?  Required
Do you have any history or mental illness including depression or anxiety?  Required
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?  Required
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?  Required
Have you ever had any of the following vaccinations / malaria tablets?  Optional

Additional Information

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