Travel Clinic Assessment Form

Date Of Birth (DD/MM/YYYY):

Gender:
MaleFemaleOther

Please list any allergies:

Please list your medical conditions:

Please list all your regular medications (regular repeat medicines, over the counter, vitamins and herbal):

Please list all vaccines you have had and when (for travel and childhood):

Any issues with your immune system (medications, treatments, myasthenia gravis, HIV)?:

Past or recent surgery?

Have you ever had cancer, leukaemia, lymphoma or had organ or bone marrow transplant? YesNo

Have you ever had any previous reactions to vaccines? YesNo

Does having an injection make you feel faint? YesNo

Do you or any close family member suffer from epilepsy? YesNo

Have you or any close family member suffered from DVT (deep vein thrombosis)? YesNo

Do you have any history of mental illness including depression or anxiety? YesNo

Are you pregnant or breastfeeding? YesNo

Women: Have you undergone FGM / been cut / female circumcision? YesNo

Date of departure:

Return Date:

Please list the Countries / Area (location is known); the length of stay in each country/area/location and how far you will be from medical help in each location? Please provide as much detail as possible

Type of trip:

Self OrganisedTrekkingCruise ShipPackage Holiday in ResortBackpackingMedical Volunteering

Accommodation:

HotelRural campingHostalOther

Area type:

RuralUrban (town/city)

Planned activities (Safari / Adventure / Other)? Please provide as many details as possible.

How far will you be from medical help?

If you already know which vaccines you require, please list them here: