Travel risk assessment

Country of origin: *

Please supply information about your trip in the sections below

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Please give details of country to be visited, exact location or region, city or rural, length of stay and how remote you’ll be from medical help:

Have you taken out travel insurance for this trip?

Yes

No

Do you plan to travel abroad again in the future?

Yes

No

Type of travel and purpose of trip

Holiday type:

Type of trip:

Business

Pleasure (holiday)

Expatriate

Other

Accommodation:

Hotel

Relatives / family home

Hostels

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Diving

Other

Additional Information:

Please supply details of your personal medical history

Are you currently fit and well?

Yes

No

Details:

Any allergies including food, latex, medication?

Yes

No

Details:

Severe reaction to a previous vaccine?

Yes

No

Details:

Tendency to faint with injections?

Yes

No

Details:

Any surgical operations in the past, e.g. your spleen or thymus gland removed?

Yes

No

Details:

Recent chemotherapy / radiotherapy / organ transplant?

Yes

No

Details:

Any anaemia?

Yes

No

Details:

Any bleeding/clotting disorders (including history of DVT)?

Yes

No

Details:

Any heart disease (e.g. angina, high blood pressure)?

Yes

No

Details:

Any diabetes?

Yes

No

Details:

Any disabilities?

Yes

No

Details:

Any epilepsy or seizures?

Yes

No

Details:

Any gastrointestinal (stomach) complaints?

Yes

No

Details:

Any Liver and/or kidney problems?

Yes

No

Details:

Any HIV/AIDS?

Yes

No

Details:

Any immune system conditions?

Yes

No

Details:

Any mental health issues (including anxiety, depression)?

Yes

No

Details:

Any neurological (nervous system) illness?

Yes

No

Details:

Any respiratory (lung) disease?

Yes

No

Details:

Any rheumatology (joint) conditions?

Yes

No

Details:

Any spleen problems?

Yes

No

Details:

Any other problems:

Women Only

Are you pregnant?

Yes

No

Details:

Are you breast feeding?

Yes

No

Details:

Are you planning pregnancy whilst away?

Yes

No

Details:

Have you undergone FGM/been cut?

Yes

No

Details:

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

Please supply information on any vaccines or malaria tablets taken in the past

Have you ever had any of the following vaccinations / malaria tablets?

Please state which year you had the vaccination(s):

Tetanus:

Polio:

Hepatitis A:

Hepatitis B:

Meningitis:

Yellow Fever:

Influenza:

Rabies:

Jap B Enceph:

Tick-borne Enceph (TBE):

Diptheria:

Typhoid:

Cholera:

MMR:

BCG:

Pneumococcal:

COVID-19 (dates, brand etc.):

Other / Malaria tablets please list here:

Any additional Information:

Patient Signature:

Date:

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent – it may take up to 2 working days before I receive a reply.

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Please supply information about your trip in the sections below

Type of travel and purpose of trip

Please supply details of your personal medical history

Women Only

Please supply information on any vaccines or malaria tablets taken in the past