Travel Risk Assessment

Sex:

Male

Female

Indeterminate

Dates of Trip

Date of Departure:

Please use this date format: DD/MM/YYYY

Return date or overall length of trip:

Please use this date format: DD/MM/YYYY

Itinerary and Purpose of Visit

Please give details of country to be visited, length of stay, and how remote you'll be from medical help:

Type of trip:

Business

Pleasure

Other

Accommodation:

Hotel

Relatives / family home

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Planned activities:

Safari

Adventure

Other

Personal Medical History

Do you have any recent or past medical history of note?

Including diabetes, heart or lung conditions, thymus disorder

List any current or repeat medications:

Do you have any allergies for example to eggs, antibiotics, nuts?

Have you ever had a serious reaction to a vaccine given to you before?

Does having an injection make you feel faint?

Do you or any close family members have epilepsy?

Do you have any history or mental illness including depression or anxiety?

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Are you pregnant or planning pregnancy or breast feeding?

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about his?

Please write below any further information which may be relevant:

Vaccincation History

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: *

Malaria tablets: *

Other please list here: *

Signed: *

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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