Travel Risk Assessment Form Travel risk assessment form Please complete this form in preparation for your travel appointment Step 1 of 4 25% Name Date of Birth DD slash MM slash YYYY Gender Male Female Prefer not to say Other Email Address Optional Date of Departure Day Month Year Date of Return Day Month Year Destination Length of Stay Will you be away from Medical help? if so, how remote?Describe your tripAll Inclusive / Cruise ShipSelf Organised / CampingBackpacking / TrekkingAccommodation TypeHotelRelatives / Family HomeOtherTravellingAloneWith Family / FriendsIn a GroupStaying in Area which isUrbanRuralAltitudePlanned ActivitiesSafariAdventureOther Personal Medical HistoryList any Current Medications Do you have any allergies, for example Eggs, Antibiotics, Nuts? Have you ever had a serious reaction to a vaccine given to you before? Does having an injection make you feel faint? Do you or any close family members have epilepsy? Do you have any history of mental illness including depression or anxiety? Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Women Only: Are you pregant or planning pregnancy or breast feeding? Have you taken out travel insurance? If you have a medical condition, have you informed the insurance company about this? Please give any further information that may relevant, including any future plans OptionalVaccination History Tetanus Polio Diphtheria Typhoid Hepatitis A Hepatitis B Meningitis Yellow Fever Influenza Rabies Jap B Enceph Tick Borne Other Malaria Tablets None on the above
