Tendency to with injections? Any surgical operations in the past, including e.g. your spleen or thymus gland removed? YES NO DETAILS 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? Liver and/or kidney problems? HIV/AIDS? Immune system condition? Mental health issues (including anxiety, depression)? Neurological (nervous system) illness? Respiratory (lung) disease? Rheumatology (joint) conditions? Spleen problems? Any other conditions? Women only Are you pregnant? Are you breast-feeding? Are you planning pregnancy while away? Are you currently taking any medication (including prescribed, purchased or a contraceptive pill?) PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST Tetanus/polio/diphtheria MMR Influenza Typhoid Hepatitis A Pneumococcal Cholera Hepatitis B Meningitis Rabies Japanese Tick Borne Encephalitis Encephalitis Yellow fever BCG Other Malaria tablets
Tendency to with injections? Any surgical operations in the past, including e.g. your spleen or thymus gland removed? YES NO DETAILS 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? Liver and/or kidney problems? HIV/AIDS? Immune system condition? Mental health issues (including anxiety, depression)? Neurological (nervous system) illness? Respiratory (lung) disease? Rheumatology (joint) conditions? Spleen problems? Any other conditions? Women only Are you pregnant? Are you breast-feeding? Are you planning pregnancy while away? Are you currently taking any medication (including prescribed, purchased or a contraceptive pill?) PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST Tetanus/polio/diphtheria MMR Influenza Typhoid Hepatitis A Pneumococcal Cholera Hepatitis B Meningitis Rabies Japanese Encephalitis Tick Borne Encephalitis Yellow fever BCG Other Malaria tablets
Travel%20risk%20assessment%20form%20(June%202018).docx