Travel Risk Assessment

In order to speed up your appointment, please fill out our risk assessment form below.

    Patient's personal details

    Mr:MissMsMrsDr
    MaleFemale

    Dates,itinerary and purpose of trip

    Personal Medical History

    Tick which of the following applies to you

    YesNo

    Are you feeling well today?

    YesNo

    Have you had any immunisations in the past 4 weeks?

    YesNo

    Do you have any recent or past medical history of note?

    YesNo

    Do you take any current or repeat medicines or are you talking halofantrine?

    YesNo

    Do you have any allergies to any medicines, latex or eggs?

    YesNo

    Have you had a serious reaction to a vaccine, antimalarial or doxycycline before?

    YesNo

    Do you known if you are hypersensitive to mefloquine or related compounds (e.g. quinine, quinidine) or excipients?

    YesNo

    Do you or any of your family suffer from epilepsy?

    YesNo

    Do you have a past history of black water fever?

    YesNo

    Do you have severe impairment of liver function?

    YesNo

    Do you suffer from any blood disorders such as thalassemia or sickle cell anaemia?

    YesNo

    Have you recently undergone radiotherapy, Chemotherapy, steroids treatments?

    YesNo

    Do you have any history of the following: anxiety, depression, heart, lung, spleen, liver, kidney, immunity, blood conditions, disorders, diabetes immunity, HIV AIDs?

    YesNo

    Vaccination History

    Have you had a vaccine, antimalarial or doxycycline before? (Please add dates)

    Women Only

    Tick which of the following applies to you

    Are you pregnant or planning a pregnancy?

    YesNo

    Are you breastfeeding?

    YesNo

    Please write below any further information which may be relevant e.g. Medicines, conditions..

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