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Travel risk assessment

Travel Risk Assessment

Section

Travel Information

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Have you taken out travel insurance for this trip? *
Do you plan to travel abroad again in the future?
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:

Personal Medical History

Are you fit and well today? *
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before? *
Do you have a tendency to faint with injections? *
Any surgical operations in the past, including open heart surgery/spleen/thymus gland removal? *
Recent chemotherapy/radiotherapy/organ transplant? *
Anaemia? *
Bleeding/clotting disorders (including history of DVT)? *
Heart disease including angina/high blood pressure? *
Diabetes? *
Additional needs and/or disability? *
Epilepsy/seizures (or in a first degree relative)? *
Gastrointestinal (stomach) complaints? *
Liver and/or kidney problems? *
HIV/Aids? *
Immune system condition ie blood cancer? *
Mental health issues including depression/anxiety? *
Neurological disorders (nervous system)? *
Respiratory disease? *
Rheumatology conditions? *
Spleen problems? *
Have you or anyone in your family undergone FGM/been cut/circumcised? *
Are you or your partner pregnant or planning a pregnancy? *
Are you breastfeeding?
Including prescribed, purchased or a contraceptive pill.

Previous Vaccinations

Have you ever had any of the following vaccinations / malaria tablets?

Please state which year/s you had the vaccination(s):

Enter full name
Confirmation