TRAVEL RISK ASSESSMENT FORM be completed by traveller prior to appointment –to Please ensure that you complete as much of this form as possible and that you have fully read the information on our website. This form should be submitted six to eight weeks before you travel. Some vaccinations incur a charge - see our website for details - and we only accept payments by cash or cheque. Name: Date of birth: Male Female Email: 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 RURAL LENGTH OF STAY REGION 1. 2. 3. Have you taken 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 Business trip Cruise ship trip Camping/hostels Expatriate Safari Adventure Volunteer work Pilgrimage Diving Healthcare worker Medical tourism Visiting friends/family Additional information PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY Yes No Details Are you fit and well today 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) disease (e.g. angina, high blood pressure) Diabetes Disability Epilepsy/seizures Gastrointestinal (stomach) complaints Liver and or kidney problems HIV/AIDS Immune system condition
TRAVEL RISK ASSESSMENT FORM –to be completed by traveller prior to appointment Please ensure that you complete as much of this form as possible and that you have fully read the information on our website. This form should be submitted six to eight weeks before you travel. Some vaccinations incur a charge - see our website for details - and we only accept payments by cash or cheque. Name: Date of birth: Male Female Email: 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 taken 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 Business trip Cruise ship trip Camping/hostels Expatriate Safari Adventure Volunteer work Pilgrimage Diving Healthcare worker Medical tourism Visiting friends/family Additional information PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY Yes No Details Are you fit and well today 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) disease (e.g. angina, high blood pressure) Diabetes Disability Epilepsy/seizures Gastrointestinal (stomach) complaints Liver and or kidney problems HIV/AIDS Immune system condition
Travel%20Risk%20Assessment%20-%20Website.docx