Travel Risk Questionnaire Travel Questionaire Please note this form should be submitted AT LEAST 10 WEEKS before travel. Once submitted please give us 2 weeks to process the form and to arrange your appointment. Name * Name First First Surname Surname Date of Birth * Phone * Email Please supply information about your trip in the sections below. Date of departure * Total duration of trip (in days) * Country/Countries to be visited 1st Country being visited * Exact location or region * City or rural? * City Rural Length of stay (include stopover destinations) * Is this the only country you will be visiting? * Yes No 2nd Country being visited Exact location or region City or rural? City Rural Length of Stay Do you need to add another country? Yes No 3rd Country being visited Exact location or region City or rural? City Rural Length of Stay If you will be visiting more countries, please enter this information under additional information at the end of this form. Have you taken out travel insurance for this trip? * Yes No Do you intend to travel abroad again in the future? * Yes No Type of travel and purpose of trip – tick all that apply. * Holiday Business trip Expatriate Volunteer work Healthcare worker Staying in hotel Cruise ship trip Safari Pilgrimage Medical tourism Backpacking Camping/hostels Adventure Diving Visiting friends/family Are you fit for travel? * Yes No Do you have any allergies (including food, latex, medication)? * Yes No State Allergies Have you had a severe reaction to a vaccine or malaria medication before? * Yes No Health conditions (tick all that apply) Tendency to faint with injections Any surgical operations in the past (including removal of spleen or thyroid gland) Recent chemotherapy/radiotherapy/organ transplant Anaemia Bleeding/clotting disorders (including history of DVT) Heart disease (e.g. angina, high blood pressure) Diabetes Additional needs/disability Epilepsy/seizures Gastrointestinal (stomach) problems Liver/kidney problems HIV/AIDs Immune system condition (e.g. blood cancer) Mental health issues (including anxiety, depression) Neurological (nervous system) illness Respiratory (lung) disease Rheumatology (joint) conditions Spleen conditions Pregnant (if applicable) Breast feeding (if applicable) Undergone FGM/been cut/circumcision Are you currently taking any medication – including prescribed, purchased or a contraceptive pill? List all below. * Which of the following vaccinations have you had in the past? (Tick all that apply) Tetanus/Polio/Diptheria Typhoid MMR Hepatitis A Hepatitis B Meningitis Cholera Rabies Japanese encephalitis Tick-borne encephalitis BCG Yellow Fever Influenza Pneumococcal Covid vaccination (dates, brand etc) Have you had malaria tablets previously? Yes No Any additional information Submit If you are human, leave this field blank.
