Travel Risk Assessment

 
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Personal Details
Gender: *
Please Supply Information About Your Trip
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: *
Please Supply Details of Your Personal Medical History
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): *
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: *
Spleen problems: *
Any other conditions?: *
Women only
Are you pregnant?:
Are you breast feeding?:
Are you planning pregnancy while away?:
Have you undergone FGM / been cut / circumcised?:
Further Questions

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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