Travel Risk Assessment Form
This form must be submitted at least 8 weeks prior to travel
Name
*
First Name
Last Name
Date of Birth
*
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Day
-
Month
Year
Address
Contact Number
Email
example@example.com
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Travel details
Departure Date
*
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Day
-
Month
Year
Departure Date
Return Date
*
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Day
-
Month
Year
Return Date
Destination(s)
*
Country
Destination(s) within the country
Length of stay
Mode of transport
1
2
3
4
5
Destination Description
*
Urban (town/city)
Coastal
Rural (countryside)
Safari
Desert
High altitude
Other (please provide details)
Destination Description - Other
Accommodation
*
Hotel
Hostel
Camping
Staying with family/friends
Other (please provide details)
Accommodation - Other
Do you have travel health insurance (covering pre-existing health conditions and planned activities if relevant)?
*
Yes
No
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Medical History
Please choose either yes or no. If you answer yes to any of the questions, please provide details below
*
Yes
No
Are you well today?
Do you have any health conditions? E.g. diabetes, respiratory (breathing) problems, heart disease, Neurological illness, liver or kidney problems, blood disorders [e.g. sickle cell disease, clotting or Bleeding issues]
Do you, or a first degree relative (parents, brother, sister or child), have epilepsy or seizures?
Have you, or a first degree relative (parents, brother, sister, or child), ever experienced any mental health issues, even mild anxiety, or depression?
Do you have, or have you had, a condition that could impair your immune system? E.g. HIV/AIDS, blood cancer
In the last 12 months, have you taken any medication or had treatment that could impair your immune system? E.g. chemotherapy, radiotherapy, high dose steroids
Have you ever had any surgery? E.g. open-heart surgery, transplant surgery, spleen or thymus gland removal
Have you ever had a travel related illness/injury that required assessment/treatment in hospital?
Are you receiving regular treatment or follow up with your GP/hospital specialist?
Do you have any disability or mobility problems?
Do you have any allergies? E.g. food, medication or latex
Have you, or anyone in your family, ever had a severe reaction to a vaccine or malaria medication?
Are you or your partner pregnant or planning a pregnancy?
Are you breastfeeding?
If you answered yes to any of the questions above, please provide details here with any other important information regarding your health, including problems experienced with previous travel:
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Vaccine History
If you have received vaccinations elsewhere which will not be in our clinic records, please provide details here
Signature
*
Date
*
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Day
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Month
Year
Date
Submit
Should be Empty: