Travel Assessment

First Name *

Last Name *

Street Address *

Street Address Line 2

City *

County *

Postal Code *

Date of Birth *

Gender *
Select genderMaleFemalePrefer not to say

Contact Number *

Email Address *

Departure Date *

Duration of Stay *

Main destination (country and region) of this trip *

Do you have travel insurance? *
Select optionYesNoNot yet

Do you have further upcoming travel plans? *
Select optionYesNoPossibly

If you answered “Yes” or “Possibly” above, please give details below

Travel type and purpose of trip (tick all that apply) *
HolidayBackpackingBusiness tripCamping/hostelsSafariVolunteer workDivingMedical tourismStaying in hotelCruise ship tripExpatriateAdventurePilgrimageHealthcare workerVisiting friends/familyOther

Your GP's Details (Doctor’s name, address and telephone number) *

Details of your personal medical history
Fit and well todayAllergies (any)Reaction to vaccineFainting with needlesPast operationsChemo/radiotherapyAnaemiaBleeding problemsHeart problemsDiabetesDisabilityFits or seizuresStomach issuesLiver/kidney issuesHIV/AIDSImmune problemsMental healthNerve problemsLung problemsJoint problemsSpleen issuesPregnant?Breastfeeding?Planning pregnancy?FGM/circumcisedOther

Are you currently taking any medication? *
Select optionYesNo

Do you have any medication allergies? *
Select optionYesNoNot sure

Vaccinations

Please tick any Vaccinations or Malaria Tablets taken in the past
TetanusPolioDiphtheriaMMRInfluenzaTyphoidHepatitis APneumococcalCholeraHepatitis BMeningitisRabiesJapanese encephalitisTick-borne encephalitisYellow feverBCGMalaria tabletsOther

Travel consultations are available at our Enniskillen branch

Location: 34–36 Darling Street, Enniskillen, BT74 7EW

I confirm that the information provided is accurate and complete and I consent to Corrys Chemists contacting me regarding my travel consultation.*