Travel risk assessment

Your country of origin:

About your trip

Date of Departure:

Please use this date format: DD/MM/YYYY

Total length of trip:

Please give details of country to be visited, the exact location or region, city or rural and length of stay:

What modes of transport will you be using?

Have you taken out travel insurance for this trip?

Yes

No

Do you plan to travel abroad again in the future?

Yes

No

Type of travel and purpose of trip

Holiday type:

Planned activities:

Accommodation:

Hotel

Relatives / family home

Hostel

Other

Travelling:

Alone

With family / friend

In a group

Staying in area which is:

Urban

Rural

Altitude

Type of trip:

Business

Pleasure

Expatriate

Other

Additional details:

Medical history

Are you fit and well today?

Yes

No

Details:

List any allergies (including food, latex, medication):

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

Yes

No

Details:

Does having an injection make you feel faint?

Yes

No

Details:

Any surgical operations in the past, including e.g. open heart surgery, spleen or thymus gland removal?

Have you recently undergone radiotherapy, chemotherapy or organ transplant?

Yes

No

Details:

Anaemia?

Yes

No

Details:

Bleeding/clotting disorders (including history of DVT)?

Yes

No

Details:

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

Yes

No

Details:

Diabetes?

Yes

No

Details:

Additional needs or disability?

Yes

No

Details:

Do you or any first degree relatives have epilepsy?

Yes

No

Details:

Gastrointestinal (stomach) complaints?

Yes

No

Details:

Liver and or kidney problems?

Yes

No

Details:

HIV/AIDS?

Yes

No

Details:

Immune system condition e.g. blood cancer?

Yes

No

Details:

Mental health issues (including anxiety, depression)?

Yes

No

Details:

Neurological (nervous system) illness?

Yes

No

Details:

Respiratory (lung) disease?

Yes

No

Details:

Rheumatology (joint) conditions?

Yes

No

Details:

Spleen problems?

Yes

No

Details:

Any other conditions?

Including diabetes, heart or lung conditions

Are you or your partner pregnant or planning a pregnancy (if applicable)?

Are you breast feeding (if applicable)?

Have you or anyone in your family undergone FGM / been cut / circumcised (if applicable)?

List any current or repeat medications:

Including prescribed, purchased or a contraceptive pill

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

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

Tetanus: *

Polio: *

Hepatitis A: *

Hepatitis B: *

Meningitis: *

Yellow Fever: *

Influenza: *

Rabies: *

Jap B Enceph: *

Tick-borne Enceph (TBE): *

Diptheria: *

Typhoid: *

MMR: *

BCG: *

COVID-19: *

Dates, brand etc.

Cholera: *

Other / Malaria tablets please list here: *

Any additional information:

Signed: *

Date:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent – it may take up to 2 working days before I receive a reply.

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About your trip

Type of travel and purpose of trip

Medical history