Travel Risk Assessment 1About You2Trip Information and Itinerary3Type of Travel and Purpose of Trip4Personal Medical History5Medication & Vaccinations6Additional Information In order to provide you with the appropriate protection during your trip we are required to complete a full Travel Risk Assessment. Please complete this form (one form per traveler) at least 6 weeks before your date of first travel to ensure that there is enough time to have all your vaccinations and we can order them in to stock. Once you have completed the form please book a Travel Clinic Appointment (one appointment per traveller) with one of our Practice Nurses. To offer you a safe and complete service we are not able to see patients without first having the opportunity to review the full information provided on this form. Your appointment with the practice nurse will not be arranged until we have processed the information you have provided. The NHS provide some travel vaccinations and medication free of charge, dependent upon the circumstances of the particular trip that you are undertaking. About YouFirst Name* Surname* Date of Birth* DD slash MM slash YYYY Enter date of birth dd/mm/yyyyGender* Male Female Email Address* Daytime Telephone Number*Mobile Number*PrivacyPrivacy Policy* I consent to the practice collecting and storing my data from this form.This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible. We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. If you are not completely happy to provide information via the internet please contact the practice directly. General Information About Your TripDate of Departure* DD dash MM dash YYYY Overall Length of Trip* e.g. 2 Weeks, 3 Months etcHave you taken out travel insurance for this trip?* Yes No Do you plan to travel abroad again in the future?* Yes No Country Visit DetailsCountry Name* Country Location or Region* Country City or Rural*CityRuralBothCountry Length of Stay* Are you visiting a second country?* Yes No Country Two Visit DetailsCountry 2 Name* Country 2 Location or Region* Country 2 City or Rural*CityRuralBothCountry 2 Length of Stay* Are you visiting a third country?* Yes No Country 3 Visit DetailsCountry 3 Name* Country 3 Location or Region* Country 3 City or Rural*CityRuralBothCountry 3 Length of Stay* Are you visiting additional countries?* Yes No Additional Country Information*For each country you are visiting please tell us the name, location or region, whether you will be staying in a city or rural location (or both) and the length of your stay in that country. Type of Travel and Purpose of TripType and Purpose of Trip* Holiday Business Trip Expatriate Volunteer work Healthcare Worker Staying in Hotel Cruise Ship Safari Pilgrimage Medical Tourism Backpacking Camping or Hostel Adventure Diving Visiting Friends or Family Please select all that applyAdditional Information OptionalPlease supply any additional details that may be relevant Personal Medical HistoryAre you fit and well today?* Yes No Tell us more about your condition(s)*Any allergies including food (eggs, nuts), latex, medication?* Yes No Tell us more about your allergies including food (eggs, nuts), latex, medication*Have you has a severe reaction to a vaccine before?* Yes No Tell us more about your vaccine reaction*Do you have a tendency to faint with injections* Yes No Have you had any surgical operations in the past, including e.g. your spleen or thymus gland removed?* Yes No Tell us more about your surgical operations*Have your recieved recent chemotherapy, radiotherapy or an organ transplant?* Yes No Tell us more about your recent chemotherapy, radiotherapy or organ transplant*Do you suffer from Anaemia?* Yes No Tell us more about your Anaemia*Do you have any bleeding or clotting disorders (including history of Deep Vein Thrombosis (DVT))?* Yes No Tell us more about your Bleeding or clotting disorders (including history of DVT)*Do you have Heart disease (e.g. angina, high blood pressure)?* Yes No Tell us about your Heart disease (e.g. angina, high blood pressure)*Do you have Diabetes?* Yes No Tell us more about your Diabetes*Do you have a Disability?* Yes No Tell us about your Disability*Do you suffer from Epilepsy or Seizures?* Yes No Please provide further information about your Epilepsy or Seizures*Do you suffer from Gastrointestinal (stomach) complaints?* Yes No Tell us about your Gastrointestinal (stomach) complaints*Do you have any Liver and or kidney problems?* Yes No Tell us about your Liver and or kidney problems*Do you have HIV or AIDS?* Yes No Tell us about your HIV or AIDS*Do you have an Immune system condition?* Yes No Tell us about your Immune system condition*Do you suffer from any Mental health issues (including anxiety, depression)?* Yes No Tell uys about your Mental Health*Do you have a Neurological (nervous system) illness?* Yes No Tell us about your Neurological (nervous system) illness*Do you have a Respiratory (lung) disease?* Yes No Tell us about your Respiratory (lung) disease*Do you have any Rheumatology (joint) conditions?* Yes No Tell us about your Rheumatology (joint) conditions*Do you have any Spleen problems?* Yes No Tell us more about your Spleen problems*Do you have any other conditions not listed above?* Yes No Tell us about your other conditions* Medication & VaccinationsAre you currently taking any medication (including prescribed, purchased or a contraceptive pill)? OptionalPlease supply information on any Vaccines or Malaria Tablets taken in the past OptionalInclude: Tetanus, Polio, Diphtheria, Measles Mumps and Rubella, Influenza, Typhoid, Hepatitis A, Hepatitis B, Pneumococcal, Cholera, Meningitis, Rabies, Japanese Encephalitis, Tick Bourne Encephalitis, Yellow Fever, Tuberculosis (TB), Malaria Tablets and any others Additional InformationAny Additional Information? OptionalComments OptionalThis field is for validation purposes and should be left unchanged.