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

Women Only

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

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