Travel Risk Assessment Form

Travel Risk Assessment Form
Traveler Information
Name
First NameLast Name
Email
example@example.com
Phone Number
Area CodePhone Number
Birth Date
MonthDayYear
Gender
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Country to be visited
Rows Yes No
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
TYPE OF TRAVEL AND PURPOSE OF TRIP
Other

Rows	Yes	No
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?

PLEASE FILL DETAILS OF YOUR PERSONAL MEDICAL HISTORY

Rows	Yes	No	Details
Are you fit and well today		6
Any allergies including food, latex, medication		8
Severe reaction to a vaccine before		10
Tendency to faint with injections		12
Any surgical operations in the past, including e.g. your spleen or thymus gland removed		14
Recent chemotherapy/radiotherapy/organ transplant		16
Anaemia		18
Bleeding /clotting disorders (including history of DVT)		20
Heart disease (e.g. angina, high blood pressure)		22
Diabetes		24
Disability		26
Epilepsy/seizures		28
Gastrointestinal (stomach) complaints		30
Liver and or kidney problems		32
HIV/AIDS		34
Immune system condition		36
Mental health issues (including anxiety, depression)		38
Neurological (nervous system) illness		40
Respiratory (lung) disease		42
Rheumatology (joint) conditions		44
Spleen problems		46
Any other conditions?		48

For women
Rows Yes No Details
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised
PLEASE SELECT THE ALL VACCINES TAKEN IN THE PAST
Other
Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?
Emergency Information
Emergency Contact's Name
First NameLast Name
Relationship
Phone Number
Area CodePhone Number
Alt. Phone Number
Area CodePhone Number
Payment
My Products
prevnext( X )
Travel Service Payment$450.00

Total $0.00
Informed Consent and Acknowledgement
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Medical Release and Authorization
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Should be Empty:

Rows	Yes	No	Details
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised

Travel Risk Assessment Form

Payment

My Products*

My Products