Travel Risk Assessment

Section

Please use this date format: DD/MM/YYYY
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:

Personal Medical History

Including food, latex, medication etc.
Are you fit and well today?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Have you recently undergone radiotherapy, chemotherapy or organ transplant?
Do you have anaemia?
Do you have bleeding/clotting disorders (including history of DVT)?
Do you have heart disease (e.g. angina, high blood pressure)?
Do you have diabetes?
Do you have a disability?
Do you have epilepsy/seizures?
Do you have gastrointestinal (stomach) complaints?
Do you have liver and or kidney problems?
Do you have HIV/AIDS?
Do you have an immune system condition?
Do you have any history or mental illness including depression or anxiety?
Do you have a neurological (nervous system) illness?
Do you have respiratory (lung) disease?
Do you have rheumatology (joint) conditions?
Do you have spleen problems?

Women only

Are you pregnant?
Are you breastfeeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised?

Vaccination History

Have you ever had any of the following vaccinations / malaria tablets?

Please state which year you had the vaccination(s):