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Travel Risk Assessment Form

Please supply information about your trip in the sections below

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

Women only

YesNo
Are you pregnant?
YesNo
Are you breast feeding?
YesNo
Are you planning pregnancy while away?
YesNo
Have you undergone FGM / been cut / circumcised

Please supply information on any vaccines or malaria tablets taken in the past (including dates)

Consent

Parental Consent for Children only