Travel risk assessment

Section

Address:

Please include postcode

Do you smoke?

Yes

No

Are you pregnant?

Yes

No

Are you breastfeeding?

Yes

No

Please list destination(s) of travel, (in date order if more than one), for each destination enter how long you will be in each country and cities visited:

Date of Departure:

Please use this date format: DD/MM/YYYY

Duration of trip:

Type of trip:

Signed:

Date:

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