Pendleside Medical Practice - Travel Risk Assessment Form

TRAVEL RISK ASSESSMENT FORM

ideally to be completed by traveller prior to appointment
Name*

First NameLast Name
Your country of origin*
Date of birth*

DayMonthYear
Gender*

MaleFemaleNon-binary
Email*
Telephone number*
Mobile number
PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW
Date of departure*

DayMonthYear
Total length of trip*
In days (e.g 7 days)

Countries to be visited*

Rows	Country	Exact location or region	City or rural	Length of stay
1.
2.
3.

What modes of transport will you be using?*
Have you taken out travel insurance for this trip?*
Do you plan to travel abroad again in the future?*
TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT APPLY*

HolidayBusiness tripExaptriateVolunteer workHealthcare workerStaying in hotelCruise ship tripSafariPilgrimageMedical tourismBackpackingCamping/hostelsAdventureDivingVisiting friends/familyOther
PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY
Are you fit and well today?*

YesNo
Any allergies including food, latex, medication?*

YesNo
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?*

YesNo
Tendency to faint with injections?*

YesNo
Any surgical operations in the past? (open heart surgery, spleen or thymus gland removal)*

YesNo
Any recent chemotherapy, radiotherapy or organ transplants?*

YesNo
Do you suffer from anaemia?*

YesNo
Bleeding/clotting disorders? (including history of DVT)*

YesNo
Heart disease? (e.g angina, high blood pressure)*

YesNo
Diabetes?*

YesNo
Any additional needs or disabilities?*

YesNo
Epilepsy/seizures (or in a first degree relative)?*

YesNo
Gastrointestinal (stomach) complaints?*

YesNo
Liver and/or kidney problems?*

YesNo
HIV/AIDS?*

YesNo
Immune system conditions? (e.g blood cancer)*

YesNo
Mental health issues (including anxiety, depression)?*

YesNo
Neurological (nervous sytem) illness?*

YesNo
Respiratory (lung) disease?*

YesNo
Rheumatology (joint) conditions?*

YesNo
Spleen problems?*

YesNo
Any other conditions?*

YesNo
Are you or your partner pregnant or planning a pregnancy?*

YesNo
Are you breast feeding? (if applicable)

YesNo
Have you or anyone in your family undergone FGM, been cut or circumcised?*

YesNo
If you have answered yes to any of the above, please provide more details here:
Are you currently taking any medication? (including prescribed, purchased or a contraceptive pill)*
PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST

Tetanus/polio/diptheriaMMRInfluenzaTyphoidHepatitis AHepatitis BPneumococcalCholeraMeningitisRabiesJapanese encephalitisTick borne encephalitisYellow FeverBCGOther
COVID-19 vaccine? (dates, brand etc.)
Malaria Tablets?
Is there any additional information you would like us to know?
Should be Empty:

TRAVEL RISK ASSESSMENT FORM