Travel Risk Assessment Form

Your full name

Your country of origin

Date of birth

Your gender

Email Address

Telephone number (mobile preferred)

Date of departure

Total length of trip

Country / Countries to be visited

Exact location or region

City or Rural?

Have you taken out travel insurance for this trip

Yes

No

Do you plan to travel abroad aging in the future?

Yes

No

Type of travel and purpose of trip (please tick all that apply)

Are you fit and well today

Yes

No

Any allergies including food, latex, medication

Yes

No

Severe reaction to a vaccine before

Yes

No

Tendency to faint with injections

Yes

No

Any surgical operations in the past including your spleen or thymus gland removed?

Yes

No

Recent chemotherapy / radiography / organ transplant

Yes

No

Anaemia

Yes

No

Bleeding / clotting disorders (including history of DVT)

Yes

No

Heart disease (e.g angina, high blood pressure)

Yes

No

Diabetes

Yes

No

Epilepsy / seizures

Yes

No

Gastrointestinal (stomach) complaints

Yes

No

Liver and or kidney problems

Yes

No

HIV / Aids

Yes

No

Immune System Conditions

Yes

No

Mental Health Issues ( including anxiety, depression)

Yes

No

Neurological (nervous system) illness

Yes

No

Respiratory (lung) disease

Yes

No

Rheumatology (joint) conditions

Yes

No

Spleen problems

Yes

No

Any other condition?

Women only

Are you pregnant?

Yes

No

Are you breast feeding?

Yes

No

Are you planning pregnancy while away?

Yes

No

Have you undergone FGM / Been cut / circumcised?

Yes

No

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

Please supply information on any vaccines or malaria tables taken in the past

Any additional information?

Old Station Surgery

About You

About your Trip

Please supply details of your personal medical history