Travel Risk Assessment Form

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Gender *

Male

Female

Date of Departure *

Please use format day/month/year e.g. 12/05/2019

Date of Return *

Please use format day/month/year e.g. 12/05/2019

Please give details of country to be visited, length of stay, and how remote you’ll be from medical help *

Type of trip *

Business

Pleasure

Other

Accommodation *

Hotel

Relatives / family home

Other

Travelling *

Alone

With family / friend

In a group

Staying in area which is *

Urban

Rural

Altitude

Planned activities *

Safari

Adventure

Other

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions) *

List any current or repeat medications *

Do you have any allergies for example to eggs, antibiotics, nuts? *

Have you ever had a serious reaction to a vaccine given to you before? *

Yes

Don’t Know

Does having an injection make you feel faint? *

Yes

Don’t Know

Do you or any close family members have epilepsy? *

Yes

Don’t Know

Do you have any history or mental illness including depression or anxiety? *

Yes

Don’t Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment? *

Yes

Don’t Know

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this? *

Yes

Don’t Know

Please type below any further information which may be relevant:

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This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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