Travel Risk Assessment Form Consent for storing submitted data Consent for storing submitted data Patient Name Date of birth: Gender: Male Female Email: Contact number: Date of departure? Total length of trip? 1st Country and exact location / region to be visited Please give details of your 1st destination including country, the exact region or location, if this is a city or rural location and the length of stay in this area. 2nd Country and exact location / region to be visited Please give details of your 2nd destination including country, the exact region or location, if this is a city or rural location and the length of stay in this area. Please write N/A if you are not visiting a second location. 3rd Country and exact location / region to be visited Please give details of your 3rd destination including country, the exact region or location, if this is a city or rural location and the length of stay in this area. Please write N/A if you are not visiting a third location. 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 Please tick all that apply. Holiday Business trip Expatriate Volunteer work Healthcare worker Staying in hotel Cruise Safari Pilgrimage Medical tourism Backpacking Camping / hostels Adventure Diving Visiting friends / family