http://www.swansurgery.co.uk/website/J82098/files/GeneralTravelAdviceLeaflet_new.pdf SWAN SURGERY TRAVEL RISK ASSESSMENT FORM Name: Date of birth Male Female □ □ E mail: Telephone number: Mobile number: PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW Date of departure: Total length of trip: COUNTRY TO BE VISITED EXACT LOCATION OR CITY OR LENGTH OF REGION RURAL STAY 1. 2. 3. Have you out travel insurance for this trip? Do you plan to travel abroad again in the future? TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT APPLY Holiday Staying in hotel Backpacking Additional information □ □ □ 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 HISTORY YES NO DETAILS Are you fit and well Any allergies including food, latex, medication Severe reaction to a vaccine before Tendency to faint with injections Any surgical operations in the past, including e.g. your spleen or thymus gland removed Recent chemotherapy/radiotherapy/organ transplant Anaemia Bleeding /clotting disorders (including history of DVT) Heart disease (e.g. angina, high blood pressure) Diabetes Disability Epilepsy/seizures Gastrointestinal (stomach) complaints
http://www.swansurgery.co.uk/website/J82098/files/GeneralTravelAdviceLeaflet_new.pdf SWAN SURGERY TRAVEL RISK ASSESSMENT FORM Name: Date of birth Male □ Female □ E mail: Telephone number: Mobile number: PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW Date of departure: Total length of trip: COUNTRY TO BE VISITED EXACT LOCATION OR REGION CITY OR RURAL LENGTH OF STAY 1. 2. 3. Have you out travel insurance for this trip? Do you plan to travel abroad again in the future? TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT APPLY □ Holiday □ Staying in hotel □ Backpacking Additional information □ 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 HISTORY YES NO DETAILS Are you fit and well Any allergies including food, latex, medication Severe reaction to a vaccine before Tendency to faint with injections Any surgical operations in the past, including e.g. your spleen or thymus gland removed Recent chemotherapy/radiotherapy/organ transplant Anaemia Bleeding /clotting disorders (including history of DVT) Heart disease (e.g. angina, high blood pressure) Diabetes Disability Epilepsy/seizures Gastrointestinal (stomach) complaints
Travel-Risk-Assessment-Form-for-website.docx