Thread: 857853 Clone of Assesment

Travel Risk Assessment Form

Please fill as accurately as possible
Name*

First NameLast Name
Date of Birth*

DayMonthYear
E-mail*
Phone Mobile
Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Date of Departure*
Return Date*
Please give details of country to be visited, length of stay, and how remote you'll be from medical help*
Type of Trip
Holiday type eg Package, Self organised, Backpacking, Camping, Cruise ship, Trekking, pilgrimage, on business, relief/aid work *
Accommodation eg Hotel, Relatives / family home, camping*
What type of area are you visiting*

Urban - General Tourist AreaRuralAltitudeOther
Do you have any of the following planned activities?*

SafariAdventureNONEOther
other... please tell us more
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)*

YesNo
Do you have any allergies for example to eggs, antibiotics, nuts?*

YesNo
Have you ever had a serious reaction to a vaccine or antimalarials given to you before?*

YesNo
Does having an injection make you feel faint?*

YesNo
Do you or any close family members have epilepsy?*

YesNo
Do you have any history of mental illness including depression or anxiety?*

YesNo
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?*

YesNo
Women only: Are you pregnant or planning pregnancy or breast feeding?

YesNo
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about his?*

YesNo
Please provide any further information which may be relevant
Vaccination History: Please tick any travel vaccine that you have previously been given

BCGCholeraTetanusPolioDiphtheriaHepatitis AHepatitis BInfluenzaJapanese EncephalitisMeningitisMMRRabiesTick-borne EncephalitisTyphoidYellow FeverOther
Vaccination History: Please tick any travel vaccine that you have previously been given*
Prefered Appointment (we will do our best to accomodate you)

DayMonthYearHourMinutesAM/PM Option
Signature: Please sign if possible
Should be Empty:

Travel Risk Assessment Form