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Travel Risk Assessment
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Your Details
Name
*
Date of Birth
*
Phone Number
Email Address
*
Gender
Male
Female
Trip Details
Departure Date
*
Trip Duration
*
Please give details of country to be visited, length of stay and how remote you will be from medical help
*
Trip Description
Purpose of Trip
Business
Pleasure
Other
Type of Trip
Package
Self-Organised
Backpacking
Camping
Cruise Ship
Trekking
Accomodation
Hotel
Friends / Family
Other
Travelling
Alone
With Friends / Family
In a Group
Location Type
Urban
Rural
Altitude
Activity Type
Safari
Adventure
Other
Personal Medical History
List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)
List all allergies that you have (eg. eggs, nuts, antibiotics)
If you have had a serious reaction to a vaccine in the past, which vaccine was it?
List all of your current medications (including oral contraception)
Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?
Yes
No
Does having an injection cause you to feel faint?
Yes
No
Do you or any close family members have epilepsy?
Yes
No
Do you have any history of mental illness including depression or anxiety?
Yes
No
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Yes
No
Have you taken out travel insurance?
Yes
No
If you have a medical condition, have you told your insurance company about it?
Yes
No
Are you pregnant, planning pregnancy or breast feeding?
Yes
No
Write below any further information that might be relevant
Vaccination History
Have you ever had any of the following vaccinations / tablets and if so, when?
Tetanus
Polio
Diphtheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Japanese B Enceph
Tick Borne
Malaria
breast Trip past,
Consent
*
I consent to the practice collecting and storing my data from this form.
THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
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