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

Women Only

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

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