Travel Clinic Risk Assessment Form 

  • Travel Clinic Risk Assessment Form

  • Date of Birth *
     - -
  • Gender*

  • Dates, itinerary and purpose of trip

  • Date of departure*
     / /
  • Date of Return*
     / /

  • Personal Medical History

    tick which of the following applies to you
  • Are you feeling well today?*
  • Do you have any allergies to any medicines, latex or eggs?*
  • Have you had any immunisations in the past 4 weeks?*
  • Do you have any recent or past medical history of note?
  • Do you take any current or repeat medicines or are you taking halofantrine?*
  • Have you had a serious reaction to a vaccine, antimalarial or doxycycline before?*
  • Do you known if you are hypersensitive to mefloquine or related compounds (e.g. quinine, quinidine) or excipients?*
  • Do you suffer from epilepsy?*
  • Do you have a past history of black water fever?*
  • Do you have severe impairment of liver function?*
  • Do you suffer from any blood disorders such as thalassemia or sickle cell anaemia?*
  • Have you recently undergone radiotherapy, chemotherapy, steroids treatment?*
  • Do you have any history of the following: anxiety, depression, heart, lung, spleen, liver, kidney, immunity, blood conditions, disorders, diabetes, immunosuppression, HIV-AIDs?*

  • Vaccination History

  • Have you had the following vaccines before?*
  • Have you had antimalarial medication or doxycycline before?

  • Women Only

  • Are you pregnant or planning a pregnancy?
  • Are you breastfeeding?
  • Should be Empty: