Travel Risk Assessment Form Full Name Date 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 Optional Any allergies including food, latex, medication Yes No Details Optional Severe reaction to a vaccine before Yes No Details Optional Tendency to faint with injections Yes No Details Optional Any surgical operations in the past, including e.g. your spleen or thymus gland removed Yes No Details Optional Recent chemotherapy/radiotherapy/organ transplant Yes No Details Optional Anaemia Yes No Details Optional Bleeding /clotting disorders (including history of DVT) Yes No Details Optional Heart disease (e.g. angina, high blood pressure) Yes No Details Optional Diabetes Yes No Details Optional Disability Yes No Details Optional Epilepsy/seizures Yes No Details Optional Gastrointestinal (stomach) complaints Yes No Details Optional HIV/AIDS Yes No Details Optional Liver and or kidney problems Yes No Details Optional Immune system condition Yes No Details Optional Mental health issues (including anxiety, depression) Yes No Details Optional Neurological (nervous system) illness Yes No Details Optional Respiratory (lung) disease Yes No Details Optional Rheumatology (joint) conditions Yes No Details Optional Spleen problems Yes No Details Optional Any other conditions? Yes No Details Optional Are you pregnant? Yes No Details Optional Are you breast feeding? Yes No Details Optional Are you planning pregnancy while away? Yes No Details Optional Are 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 Optional Typhoid Optional Cholera Optional Rabies Optional Yellow Fever Optional MMR Optional Hepatitis A Optional Hepatitis B Optional Japanese Encephalitis Optional BCG Optional Influenza Optional Pneumococcal Optional Meningitis Optional Tick Borne Encephalitis Optional Malaria Tablets Optional Other Optional Any additional information Optional
