Travel Risk Assessment Form
Corry Chemists
Your Personal Details
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
County
Postal Code
What is your Date of Birth
*
Date
What is your gender?
*
Please Select
Male
Female
Prefer not to say
Please state your gender
Contact Phone Number
*
Please enter a valid phone number.
Format: 000 0000 0000.
Email Address
*
example@example.com
Please provide the details of your trip
Departure date
*
-
Day
-
Month
Year
Date
Duration
*
Please state days/weeks/months
Have you travel insurance
*
Yes
No
Not Yet
Have you further upcoming travel plans
*
Yes
No
Possibly
Further Travel Plans
Please provide details
If more than three please detail in additional information sectione a question
*
Rows
Country Visited
Location/Region
Duration of Stay
Urban/Rural
First
Second
Third
Travel type and purpose of trip (tick all that apply)
*
Holiday
Staying in hotel
Backpacking
Additional information
Business trip
Cruise ship trip
Camping/hostels
Expatriate
Safari
Adventure
Volunteer work
Pilgrimage
Diving
Healthcare worker
Medical tourism
Visiting friends/family
Other
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 today
Allergies (any)
Reaction to vaccine
Fainting with needles
Past operations
Chemo/radiotherapy
Anaemia
Bleeding problems
Heart problems
Diabetes
Disability
Fits or seizures
Stomach issues
Liver/kidney issues
HIV/AIDS
Immune problems
Mental health
Nerve problems
Lung problems
Joint problems
Spleen issues
Other conditions
Pregnant?
Breastfeeding?
Planning pregnancy?
FGM/circumcised
Other
Please provide details for any health conditions selected above
*
Are you currently taking any medication?
*
Yes
No
Do you have any medication allergies?
*
Yes
No
Not 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
Tetanus
Polio
Diphtheria
MMR
Influenza
Typhoid
Hepatitis A
Pneumococcal
Cholera
Hepatitis B
Meningitis
Rabies
Japanese encephalitis
Tick-borne encephalitis
Yellow fever
BCG
Malaria tablets
Other
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 7AR
Corrys Chemists Enniskillen: 34-36 Darling Street, Enniskillen, BT74 7EW
Submit
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