Pre Travel Health Assessment
Patient Name: *
Date of Birth: *
Please use the format of 00/00/00
Date of Departure: *
Please use the format of 00/00/00
Date of Return: *
Please use the format of 00/00/00
Country(s) to be visited: *
For how long: *
Type of trip: *
Business
Pleasure
Other
Holiday type: *
Package
Camping
Backpacking
Cruise
Other
Area staying in: *
Urban
Rural
Altitude
Planned activities: *
Safari
Adventure
Other
Allergies?: *
Yes
No
If yes, please state allergy details:
e.g. Eggs/Antibiotics/Nuts
Pregnant?: *
Yes
No
Breastfeeding?: *
Not Applicable
No
Yes
Smoking status: *
Smoker
Ex-smoker
non-smoker
Does having an injection make you feel faint?: *
Yes
No
Any previous adverse reaction to immunisations?: *
Yes
No
If yes, please state reaction details:
Have you taken out travel insurance and if you have a medical condition have you informed your insurance company about this?: *
Yes
No
Please list any medications: *
Combined Oral Contraception: *
Yes
No
Do you have any recent or past medical history e.g. Diabetes, Heart or Lung condition?: *
Yes
No
If yes, Please give details of the history:
Have you recently had Radiotherapy, Chemotherapy or Steroid treatment?: *
Yes
No
If yes, please give details of your treatment:
Previous Anti-Malarial medication: *
Yes
No
Type the following:
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