Travel Risk Assessment Form

Travel Risk Assessment Form

Corry Chemists
Your Personal Details
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postcode
What is your Date of Birth
Date
What is your gender?*
Please state your gender
Contact Type Number*
A phone number we can conntact you on
Email Address*
your email address
Please provide the details of your trip
Departure date*

DayMonthYear
Date
Duration*
Please state days/weeks/months
Have you travel insurance*

YesNoNot Yet
Have you further upcoming travel plans*

YesNoPossibly
Further Travel Plans
Please provide details

Destinations - If more than three please detail in additional information section*

	Country Visited	Location/Region	Duration of Stay	Urban/Rural
First
Second
Third

Travel type and purpose of trip (tick all that apply)*

HolidayStaying in hotelBackpackingAdditional informationBusiness tripCruise ship tripCamping/hostelsExpatriateSafariAdventureVolunteer workPilgrimageDivingHealthcare workerMedical tourismVisiting friends/familyOther
Medical and medication history
Your GP's Details*
Please provide your Doctor's Name, Address and Telephone Number
Details of your personal medical history

Fit and well todayAllergies (any)Reaction to vaccineFainting with needlesPast operationsChemo/radiotherapyAnaemiaBleeding problemsHeart problemsDiabetesDisabilityFits or seizuresStomach issuesLiver/kidney issuesHIV/AIDSImmune problemsMental healthNerve problemsLung problemsJoint problemsSpleen issuesOther conditionsPregnant?Breastfeeding?Planning pregnancy?FGM/circumcisedOther
Please provide details for any health conditions selected above*
Are you currently taking any medication?*

YesNo
Do you have any medication allergies?*

YesNoNot Sure
Please list your current medications and any allergy concerns*
(Include prescribed, purchased, or contraceptive pill)
Vaccinations
Please tick any Vaccinations or Malaria Tablets taken in the past

TetanusPolioDiphtheriaMMRInfluenzaTyphoidHepatitis APneumococcalCholeraHepatitis BMeningitisRabiesJapanese encephalitisTick-borne encephalitisYellow feverBCGMalaria tabletsOther
Details including dates of any items ticked above*
Please also detail any additional information you think may be relevant
Finally, please select a Corrys Chemists Branch*

Corrys Chemists Castlederg: 13-14 The Diamond, Castlederg, BT81 7ARCorrys Chemists Enniskillen: 34-36 Darling Street, Enniskillen, BT74 7EW
Should be Empty:

Travel Risk Assessment Form

Your Personal Details

Please provide the details of your trip

Medical and medication history

Vaccinations