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

Women Only

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

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