Travel Risk Assessment Travel Risk Assessment Step 1 of 4 25% Name First Last Sex Male Female Other Date of Birth Day Month Year Email Contact NumberDate of Departure Day Month Year Total Length of Trip Section BreakPlease list the following: Country to be visited, Exact location or region, City, Length of visitHave you taken out travel insurance for this trip? Yes No Type of trip Holiday Business Trip Expatriate Volunteer Work Healthcare Worker Staying in Hotel Cruise Ship Trip Safari Pilgrimage Medical Tourism Backpacking Camping / Hostel Adventure Diving Visiting Friends/Family Are you fit and well today? Yes No Any allergies including food, latex, medication? Yes No Have you had a severe reaction to a vaccine before? Yes No Tendency to faint with injections? Yes No Any surgical operations in the past, including e.g. your spleen or thymus gland removed? Yes No Recent chemotherapy/radiotherapy/organ transplant? Yes No Anaemia? Yes No Bleeding/clotting disorders (including history of DVT)? Yes No Heart disease (e.g. angina, high blood pressure)? Yes No Diabetes? Yes No Disability? Yes No Epilepsy/seizures? Yes No Gastrointestinal (stomach) complaints? Yes No Liver and or kidney problems? Yes No HIV/AIDS? Yes No Immune system condition? Yes No Mental health issues (including anxiety, depression)? Yes No Neurological (nervous system) illness? Yes No Respiratory (lung) disease? Yes No Rheumatology (joint) conditions? Yes No Spleen problems? Yes No Any other conditions? Yes No Are you pregnant? (Women only) Yes Optional No Optional Are you breast feeding? (Women only) Yes Optional No Optional Are you planning pregnancy while away? (Women only) Yes Optional No Optional Give more details for any of the above Optional Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?Please supply information on any vaccines or malaria tables taken in the past Hepatitis A Optional Hepatitis B Optional Influenza Optional Japanese Encephalitis Optional Malaria Tablets Optional Meningitis Optional MMR Optional Pneumococcal Optional Rabies Optional Tetanus/polio/diphtheria Optional Tick Borne Encephalitis Optional Typhoid Optional Yellow fever Optional Other Optional Additional vaccine information Optional
