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

Women Only

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

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