Travel Risk Assessment Form Full NameDate of Birth Day Month Year Gender Male Female Address Street Address Address Line 2 City Postcode Contact NumberEmail Enter Email Confirm Email PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOWUK Departure Date Day Month Year Total duration of trip (in days)Please enter a number from 0 to 99999.Trip DetailsCOUNTRY TO BE VISITEDEXACT LOCATION OR REGIONCITY OR RURALLENGTH OF STAY Add RemoveHave you taken out travel insurance for this trip? Yes No Do you plan to travel abroad again in the future? Yes No Don’t Know TYPE OF TRAVEL AND PURPOSE OF TRIP – PLEASE TICK ALL THAT APPLY Holiday Staying in hotel Backpacking Business trip Cruise ship trip Camping/hostels Expatriate Safari Adventure Volunteer work Pilgrimage Diving Healthcare worker Medical tourism Visiting friends/family PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORYAre you fit and well today? Yes No Details OptionalAny allergies including food, latex, medication Yes No Details OptionalSevere reaction to a vaccine before Yes No Details OptionalTendency to faint with injections Yes No Details OptionalAny surgical operations in the past, including e.g. your spleen or thymus gland removed Yes No Details OptionalRecent chemotherapy/radiotherapy/organ transplant Yes No Details OptionalAnaemia Yes No Details OptionalBleeding /clotting disorders (including history of DVT) Yes No Details OptionalHeart disease (e.g. angina, high blood pressure) Yes No Details OptionalDiabetes Yes No Details OptionalDisability Yes No Details OptionalEpilepsy/seizures Yes No Details OptionalGastrointestinal (stomach) complaints Yes No Details OptionalHIV/AIDS Yes No Details OptionalLiver and or kidney problems Yes No Details OptionalImmune system condition Yes No Details OptionalMental health issues (including anxiety, depression) Yes No Details OptionalNeurological (nervous system) illness Yes No Details OptionalRespiratory (lung) disease Yes No Details OptionalRheumatology (joint) conditions Yes No Details OptionalSpleen problems Yes No Details OptionalAny other conditions? Yes No Details OptionalAre you pregnant? Yes No Details OptionalAre you breast feeding? Yes No Details OptionalAre you planning pregnancy while away? Yes No Details OptionalAre you currently taking any medication (including prescribed, purchased or a contraceptive pill)? OptionalPLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PASTTetanus/polio/diphtheria OptionalTyphoid OptionalCholera OptionalRabies OptionalYellow Fever OptionalMMR OptionalHepatitis A OptionalHepatitis B OptionalJapanese Encephalitis OptionalBCG OptionalInfluenza OptionalPneumococcal OptionalMeningitis OptionalTick Borne Encephalitis OptionalMalaria Tablets OptionalOther OptionalAny additional information Optional
