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

Women Only

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

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