TRAVELRISKASSESSMENT FORM-tobecompleted bytravellerpriortoappointment

Master/ Mr/Miss/Mrs/Ms/Dr: / Dateof birth:
Name and address:
POST CODE: / Male □ Female□
Marital status:
email:
Occupation: / Telephone number:
Mobilenumber:
Name and address of your GP:
What is the reason for your attendance today? - PLEASE TICK ALL THAT APPLY
□Travel advice □Vaccination □Malaria tablets □A Full Travel Health Assessment □Other
Please supply information about your trip in the sections below
Dateof departure: / Totallengthof trip:
COUNTRYTO BEVISITED / EXACTLOCATIONORREGION / CITYORRURAL / LENGTHOF STAY
1.
2.
3.
Doyouplan totravelabroadagaininthe future?
Accommodation - PLEASE TICK ALL THAT APPLY
□Camping □Cruise □Hostel □Hotel □Residential □Unknown/ Other
Purpose of your Trip -PLEASE TICK ALL THAT APPLY
□Assignment □ Business □ Emigrating/ Expatriate □ Hajj/ Pilgrimage
□ Holiday □ Non Government Organisation □ Visiting Friends and Relatives
Type of Travel and Activity - PLEASE TICK ALL THAT APPLY
□Volunteer/ Aid Work
□Healthcare worker
□ Medicaltourism
□Remote Location / □Adventure
□Safari
□Backpacking
□Adventure / □ Diving
□Scuba Diving
□Swimming
(Fresh water) / □Contact Sport
□Hiking or Trekking
□Mountaineering
□Other ExtremeSports
PLEASESUPPLYDETAILSOFYOURPERSONAL MEDICAL HISTORY
YES / NO / DETAILS
Areyoufitand welltoday
Any allergiesincludingfood,latex,medication
Severereactiontoavaccinebefore
Tendency tofaintwithinjections
Any surgicaloperations inthepast,includinge.g.your
spleenorthymus glandremoved
Recentchemotherapy/radiotherapy/organtransplant
Anaemia
Bleeding/clottingdisorders(includinghistory ofDVT)
Heart disease(e.g. angina, highbloodpressure)
Diabetes
Disability
Gastrointestinal (stomach) complaints
Liver and or kidney problems
HIV/AIDS
Immunesystem condition
Epilepsy /seizures
Mentalhealth issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleenproblems
Any other conditions?
Womenonly
Areyoupregnant?
Areyoubreastfeeding?
Areyou planningpregnancy whileaway?

Are you currently takingany medication(including prescribed,purchasedoracontraceptivepill)?

Any additionalinformation

PLEASESUPPLY INFORMATIONONANYVACCINES OR MALARIATABLETSTAKEN INTHEPAST
DATE DATE DATE
Tetanus/polio/diphtheria / MMR / Influenza
Typhoid / HepatitisA / Pneumococcal
Cholera / HepatitisB / Meningitis
Rabies / Japanese
Encephalitis / Tick Borne
Encephalitis
Yellow fever / BCG / Other
MalariaTablets
How did you hear about Travel Klinix?
□Google □Other internet search □Friend/ Family □GP Practice □Poster/ Leaflet □Other If other please specify:
Thank you

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Revised 6th October 2015