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

Women Only

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

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