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

Women Only

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

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