Aesthetic Travel Risk Assessment Form

First Name

Last Name

Country of origin

Gender

Date of Departure

Date of Birth

Phone/Mobile

Total Length of trip:

Country 1	Exact Location or Region	City or Rural	Length of Stay

Country 2	Exact Location or Region	City or Rural	Length of Stay

Country 3	Exact Location or Region	City or Rural	Length of Stay

What modes of transport will you be using?

Have you taken out travel insurance for this trip?

Do you plan to travel abroad again in the future?

Please answer yes or no for the following amd provide any additional information in the section at the end:

PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY

	Yes	No
Are you fit and well today
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?
Tendency to faint with injections
Any surgical operations in the past, including e.g. open-heart surgery, spleen or thymus gland removal?
Recent chemotherapy/radiotherapy/organ transplant
Anaemia
Bleeding /clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Diabetes
Additional needs and/or disability
Epilepsy/seizures (or in a first degree relative?)
Gastrointestinal (stomach) complaints
Liver and or kidney problems
HIV/AIDS
Immune system condition e.g. blood cancer
Mental health issues (including anxiety, depression)
Respiratory (lung) disease
Neurological (nervous system) illness
Rheumatology (joint) conditions
Spleen problems
Any other conditions?
Are you or your partner pregnant or planning a pregnancy?
Are you breast feeding (if applicable)
Have you or anyone in your family undergone FGM / been cut / circumcised

Additional Information for all the questions marked as YES above:

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST

Tetanus/polio/diphtheria	Typhoid	Cholera	Rabies	Yellow fever	Meningitis	Malaria Tablets	Pneumococcal

MMR	Hepatitis A	Hepatitis B	Rabies	Japanese encephalitis	BCG	Influenza	Tick borne encephalitis

COVID-19 (dates, brand etc.)	Any additional information