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Travel risk assessment

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?
Type of travel and purpose of trip – please tick all that apply

Please supply details of your personal medical history

Are you fit and well today?
Any allergies including food, latex or medication?
Severe reaction to a vaccine before?
Tendency to faint with injections?
Any surgical operations in the past, including e.g. your spleen or thymus gland removed?
Recent chemotherapy / radiotherapy / organ transplant?
Anaemia / bleeding / clotting disorders (including history of DVT)?
Heart disease (e.g. angina, high blood pressure)?
Diabetes?
Disability?
Epilepsy / seizures?
Gastrointestinal (stomach) complaints?
Liver and kidney problems?
HIV / AIDS
Immune system condition?
Mental health issues (including anxiety, depression)?
Neurological (nervous system) illness?
Respiratory (lung) disease?
Rheumatology (joint) conditions?
Any other conditions?

Women only

Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?

Please supply information on any vaccines or malaria tablets taken in the past

Please visit the NathNac travel advise website before submitting this form so that you are aware of the travel advice and vaccine requirements for your destination: NaTHNaC – Country List (www.travelhealthpro.org.uk)

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