TRAVEL CLINIC INFORMATION FORM

Section 1 - Personal Details

Your gender

Your gender

Section 2 - Travel Details

Have you taken out Insurance for this trip?

Have you taken out Insurance for this trip?

Do you intend to travel abroad again in the near future?

Do you intend to travel abroad again in the near future?

Type of travel and purpose of trip - please select all that apply

Section 3 - Medical Information

Please provide details of your personal medical history

Are you fit and well today?
Any allergies including food, latex, medication?
Severe reaction to vaccine before?
Tendency to faint with injections?
Any surgical operations in the past? Including, e.g your spleen or thymus gland removed.
Recent Chemotherapy/radiotherapy/organ transplant?
Anaemia
Bleeding/clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Diabetes
Disability
Epilepsy / Seizures
Gastrointestinal (stomach) complaints
Liver or kidney problems
HIV / AIDS
Immune system condition
Mental health issues (including anxiety, depression)
Neurological  (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions not mentioned above
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?

Are you currently taking any medication?

Please tick all that apply for any vaccines or malaria tablets taken in the past

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