Travel Risk Assessment Form

Ideally to be completed by traveller prior to appointment

Your Details

Name (optional)

Date of birth (optional)

Email (optional)

Contact Number (optional)

Your Country of origin (optional)
Please Supply Information about your trip in the sections below

Please give as much detail as possible please

Date of departure

Total length of trip

Country to be visited

Exact Location or region

City or Rural

Length of Stay

What modes of transport will you be using ? (optional)

Have you taken out travel insurance for this trip ? (optional)

Do you plan to travel abroad again in the future ? (optional)
Type of travel and purpose of trip

Type of travel, Please tick all that apply

Holiday

Expatriate

Business Trip

Volunteer work

Healthcare worker

Staying in hotel

Cruise ship trip

Safari

Pilgrimage

Medical Tourism

Backpacking

Adventure

Diving

Camping/ Hostel

Visiting friends/family

Additional Information (optional)
Please supply details of your personal medical history

Are you fit and well today

Any Allergies including food, latex medication ? please give details if necessary

Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before ?please give details if necessary

Tendency to faint with injection

Yes

No

Any surgical operations in the past, including eg open-heart surgery, spleen or thymus gland removal ? please give details if necessary

RECENT CHEMOTHERPAY/RADIOTHERAPY/ ORGAN TRANSPLANT please give details if necessary

ANAEMIA

Yes

No

BLEEDING/CLOTTING DISORDER (INCLUDING HISTORY OF DVT) please give details if necessary (optional)

HEART DISEASE ( E.G ANGINA, HIGH BLOOD PRESSURE ) please give details if necessary

DIABETES ? please give details if necessary

ADDITIONAL NEEDS and/or disability ? please give details if necessary

Epilepsy /seizures (or in a first degree relative) ? please give details if necessary

GASTROINTESTINAL (STOMACH) COMPLAINTS please give details if necessary (optional)

LIVER AND OR KIDNEY PROBLEMS please give details if necessary

HIV/AIDS ?please give details if necessary

Immune system condition ie blood cancer ? please give details if necessary

MENTAL HEALTH ISSUES (INCLUDING ANXIETY, DEPRESSION) ? please give details if necessary

NEUROLOGICAL (NERVOUS SYSTEM) ILLNESS ?please give details if necessary

RESPIRATORY (LUNG) DISEASE ?please give details if necessary

RHEUMATOLOGY (JOINT) DISEASE ? please give details if necessary

Spleen problems ? please give details if necessary

Any other conditions

Are you or your partner pregnant or planning a pregnancy ?

Yes

No

Are you breast feeding (if applicable) (optional)

Yes

No

Have you or anyone in your family undergone GFM/been cut/circumcised ?
ARE YOU CURRENTLY TAKING ANY MEDICATION( INCLUDING PRESCRIBED, PURCHASED OR CONTRACEPTIVE PILL)

ARE YOU CURRENTLY TAKING ANY MEDICATION( INCLUDING PRESCRIBED, PURCHASED OR CONTRACEPTIVE PILL) (optional)
PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST

TETANUS (optional)

MMR (optional)

INFLUENZA (optional)

TYPHOID (optional)

HEPATITIS A (optional)

HEPATITIS B (optional)

PNEUMOCOCCAL (optional)

CHOLERA (optional)

MENINGITIS (optional)

RABIES (optional)

JAPANESE ENCEPHALITIS (optional)

BCG (optional)

YELLOW FEVER (optional)

TICK BORNE ENCEPHALITIS (optional)

COVID 19 (BRANDS AND DATES) (optional)

MALARIA TABLETS (optional)
ANY ADDITIONAL INFORMATION

PLEASE ADD ANY ADDITIONAL INFORMATION YOU WOULD LIKE TO SHARE (optional)

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Travel Risk Assessment Form

Travel Risk Assessment Form

Your Details

Please Supply Information about your trip in the sections below

Type of travel and purpose of trip

Please supply details of your personal medical history

ARE YOU CURRENTLY TAKING ANY MEDICATION( INCLUDING PRESCRIBED, PURCHASED OR CONTRACEPTIVE PILL)

PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST

ANY ADDITIONAL INFORMATION