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Travel risk assessment

Travel Risk Assessment

Please use this date format: DD/MM/YYYY
Have you taken out travel insurance?
Do you plan to travel abroad again in the future?
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Including diabetes, heart or lung conditions
Are you fit and well today?
For example, food, latex, medication
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?
Does having an injection make you feel faint?
Have you had any surgical operations in the past, including e.g. open heart surgery, spleen or thymus gland removal?
Have you recently undergone radiotherapy, chemotherapy or had an organ transplant?
Do you have anaemia?
Do you have, or have you ever had, any bleeding or clotting disorders (including a history of DVT)?
Do you have heart disease?
For example, angina or high blood pressure
Do you have diabetes?
Do you have any additional needs or a disability?
Do you or any close family members have epilepsy?
Do you have any gastrointestinal (stomach or digestive) problems?
Do you have any liver or kidney problems?
Do you have HIV or AIDS?
Do you have an immune system condition (for example, blood cancer)?
Do you have any history or mental illness including depression or anxiety?
Do you have a neurological (nervous system) illness?
Do you have a respiratory (lung) disease?
Do you have a rheumatology (joint) condition?
Do you have any problems with your spleen or have you had your spleen removed?
Do you have any other medical conditions?
Have you or anyone in your family undergone FGM (also known as being cut or circumcised)?
Have you ever had any of the following vaccinations / malaria tablets?

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

Please include, dates, brand etc.
Confirmation