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

Women Only

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

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