Travel Risk Assessment

Section

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Dates of trip

Please use this date format: DD/MM/YYYY

Itinerary and purpose of visit

Without this information we are unable to give you advice
Type of trip:
Holiday type:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Will you ever be 24 hours or more away from the nearest medical centre where you are staying?
Is your flight direct to that country from the UK?

Personal medical history

Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Have you ever had measles and or mumps?
Do you or any close family members have epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you had any operations including removal of your spleen?
Have you had removal of your thymus gland?
Have you ever had DiGeorges Syndrome or Myasthaenia Gravis?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Are you registered at the surgery?
Provide details of the surgery you are registered with

Please obtain a summary of any current medical conditions, allergies, medication and previous vaccinations you have had from your doctor.

Vaccination history

Have you ever had any of the following vaccinations / malaria tablets?
Terms and conditions
By patient or parent/guardian if under 16