PRE-TRAVEL RISK ASSESSMENT FORM

TRAVELER NAME	GENDER	DATE OF BIRTH	DATE OF DEPARTURE	DATE OF RETURN

WILL YOU BE TRAVELING ALONE OR IN A GROUP?
PURPOSE OF TRAVEL
WHAT ACTIVITIES OR EXCURSIONS DO YOU HAVE PLANNED?

DESTINATION / AREA OF TRAVEL in order of visit	DURATION OF STAY	LIVING ACCOMMODATION e.g. hotel, hostel, tent, family home	MODE(S) OF TRANSPORTATION

MEDICAL HISTORY
MEDICAL CONDITION(S) current and previous
CURRENT MEDICATION(S) please list dosage and frequency
ALLERGIES if any
REACTIONS TO PREVIOUS VACCINES if any
Have you recently had surgery?
Have you previously taken malaria tablets? If so, please list the name of each.
Please add any additional information you feel is relevant.

Prior to making an appointment, please submit completed form to:

Please allow 48 hours after submitting this form to call to make an appointment at our office.

Remember to bring an updated record of any vaccinations you have received to your appointment.

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