Travel Risk Assessment Form

Ideally to be completed by traveller prior to appointment.

Name

Your country of origin

Date of birth

Gender

Address (including post code)

Telephone number

Mobile number

Please supply details of your personal medical history

Are you fit and well today

Details

Any allergies including food, latex, medication

Details

Severe reaction to a vaccine before

Details

Tendency to faint with injections

Details

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

Details

Recent chemotherapy/radiotherapy/organ transplant

Details

Anaemia

Details

Bleeding /clotting disorders (including history of DVT)

Details

Heart disease (e.g. angina, high blood pressure)

Details

Diabetes

Details

Disability

Details

Epilepsy/seizures

Details

Gastrointestinal (stomach) complaints

Details

Liver and or kidney problems

Details

HIV/AIDS

Details

Immune system condition

Details

Mental health issues (including anxiety, depression)

Details

Neurological (nervous system) illness

Details

Respiratory (lung) disease

Details

Rheumatology (joint) conditions

Details

Spleen problems

Details

Any other conditions?

Details

Women Only

Are you pregnant?

Details

Are you breast feeding?

Details

Are you planning pregnancy while away?

Details

Have you undergone FGM / been cut / circumcised

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

Tetanus/polio/diphtheria

Typhoid

Cholera

Rabies

Yellow fever

MMR

Hepatitis A

Hepatitis B

Japanese encephalitis

BCG

Influenza

Pneumococcal

Meningitis

Tick borne encephalitis

Other

Any additional information

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