Travel Risk Assessment Form

Please complete this form prior to your travel appointment and return to reception.
Forename:					Surname:					
DOB:		           				Age:						
Address:											
												
						Postcode:					
Telephone No:                                             Mobile No: 					 
Email address:										
Date form completed: ____________   	Date of Departure:				         
Return date or overall length of trip:							

Countries to be visited (please also list the exact areas within the countries)	Length of stay	Away from medical help at destination, if so, how remote?	

			

If more than 5 countries to be visited - please continue list overleaf.

Please circle as appropriate below to best describe your trip.

1. Type of trip:	Business	Pleasure	Other	
2. Holiday Type:	Package	Self-organised	Backpacking	
	Camping	Cruise Ship	Trekking	
3. Accommodation:	Hotel/resort	Relatives	Other	
4. Travelling:	Alone	With Family/friend	In a group	
5. Staying in area which is:	Urban	Rural	Altitude	
6. Planned activities:	Safari	Adventure	Other	

Personal Medical History
Do you have any recent or past medical history of note? (Including diabetes, heart or lung conditions, and thymus disorder):
	
List any current or repeat medications:

Do you have any allergies for example to eggs, antibiotics, nuts?
	
Have you ever had a serious reaction to a vaccine given to you before? 
	
Does having an injection make you feel faint?
	
Do you or any close family members have epilepsy?
	
Do you have any history or mental illness including depression or anxiety?
	
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
	
Women only: Are you pregnant or planning pregnancy or breastfeeding?
	
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about his?
	
Please write below any further information which may be relevant:

Vaccination History
Have you ever had any of the following vaccinations/malaria tablets that we do not know about and if so when?

Tetanus		Polio		Diphtheria		
Typhoid		Hepatitis A		Hepatitis B		
Meningitis		Yellow Fever		Influenza		
Rabies		Jap B Enceph		Tick Borne		
Other		
Malaria Tabs