YES/NO
DETAILS
Are you fit and well today
Any allergies including food, latex, medication
Severe reaction to a vaccine before
Tendency to faint with injections
Any surgical operations in the past, including e.g. your spleen or thymus gland removed
Recent chemotherapy/radiotherapy/organ transplant
Anaemia
Bleeding /clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal (stomach) complaints
Liver and or kidney problems
HIV/AIDS
Immune system condition
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions?
Women Only
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised