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Are You Pregnant? Required
Are You Breast Feeding? Required
Are You Planning Pregnancy While Away? Required

Women Only

Disability? Required
Heart disease (e.g. angina, high blood pressure)? Required
Epilepsy/Seizures? Required
Diabetes? Required
Spleen problems? Required
Anemia? Required
Bleeding /clotting disorders (including history of DVT)? Required
Type of Travel and Purpose of Trip - Tick All That Apply Required

Country to be Visited

Exact Location/Region

City or Rural?

Length of Stay (Days)

Please Supply Information About Your Trip Below

TRAVEL RISK ASSESSMENT FORM

Ideally to be completed by traveller prior to appointment.

Thank You For Submitting Your Travel Assessment Form

Please Supply Details of Your Personal Medical History

Are You Fit and Well Today? Required
Any Allergies Includng Food, Latex, Medication? Required
Severe Reaction to a Vaccine Before? Required
Tendency to Faint With Injections? Required
Any surgical operations in the past, including e.g. your spleen or thymus gland removed? Required
Recent chemotherapy/radiotherapy/organ transplant? Required
Gastrointestinal (stomach) complaints? Required
Liver and or kidney problems? Required
HIV/AIDS? Required
Immune System Condition? Required
Mental health issues (including anxiety, depression)? Required
Neurological (nervous system) illness? Required
Respiratory (lung) disease? Required
Rheumatology (joint) conditions? Required
Please Supply Information on any Vaccines or Malaria Tablets Taken In The Past Required
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