Travel Risk Assessment Form - Welcome to Lordswood Medical Group

Skip to content

Search this website

Menu

Welcome to Lordswood Medical Group
Join Our Team

Home » Travel Risk Assessment Form

Travel Risk Assessment Form

If you are travelling abroad please complete and submit the travel form in plenty of time, we recommend 2 to 3 months before your journey.

Your Details

Full Name

Date of Birth

Gender

Email

Contact Number

Trip Details

Date of Departure

Total Length of Trip

Countries to be Visited

Have you taken out travel insurance for this trip?

Yes No

Do you plan to travel abroad again in the future?

Yes No

Type of Travel and Purpose of Trip - Tick all that apply

Holiday Business trip Expatriate Volunteer work Healthcare worker Staying in hotel Cruise ship trip Safari Pilgrimage Medical tourism Backpacking Camping/hostels Adventure Diving Visiting friends/family

Please Supply Details of Your Personal Medical History
Answer yes/no then give further details below

Are you fit and well

Yes No

Any allergies including food, latex, medication

Yes No

Severe rection to a vaccine before

Yes No

Tendancy to faint with injections

Yes No

Any past surgical operations including spleen or thymus gland removal

Yes No

Recent chemotherapy/radiotherapy/organ transplant

Yes No

Anaemia

Yes No

Bleeding/clotting disorders (including history of DVT)

Yes No

Heart disease (e.g. angina, high blood pressure)

Yes No

Disability

Yes No

Epilepsy/seizures

Yes No

Gastrointestinal (stomach) coplaints

Yes No

Liver and/or kidney problems

Yes No

HIV/AIDS

Yes No

Immune system condition

Yes No

Mental health issues (including anxiety, depression)

Yes No

Neurological (nervous system) illness

Yes No

Rheumatology (joint) conditions

Yes No

Spleen problems

Yes No

Have you undergone FGM/been cut/circumcised

Yes No

Are you pregnant?

Yes No N/A

Are you breast feeding?

Yes No N/A

Are you planning pregnancy while away?

Yes No N/A

Please give further details of any conditions stated above

Please give details of any medication you are taking (including prescribed, purchased, and contraceptives)

Please supply details of any vaccines or malaria tablets taken in the past
Answer yes/no then give further details below

Tetanus/Polio/Diptheria

Yes No

MMR

Yes No

Influenza

Yes No

Typhoid

Yes No

Hepatitis A

Yes No

Pneumococcal

Yes No

Cholera

Yes No

Hepatitis B

Yes No

Meningitis

Yes No

Rabies

Yes No

Japanese encephalitis

Yes No

Tick borne encephalitis

Yes No

Yellow fever

Yes No

BCG

Yes No

Malaria tablets

Yes No

Any other

Yes No

Please give further details of any vaccinations/malaria tablets not stated above

Any additional information

I consent to being contacted via the details given above. Please read our privacy policy

Support links

Privacy Policy
FAQ
Feedback
Accessibility Statement
Help

Page last reviewed: 15 March 2021
Next review due: 15 March 2024

© Copyright, Welcome to Lordswood Medical Group 2023
Version 3.1

Website Feedback

Name

Email address

Message