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

Women Only

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

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