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Moordown Medical Centre

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Carers
eConsult
New Patients
Appointments
Prescriptions
Services
Patient Record
Self Help and Health Advice
Online Forms- COMING SOON

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Travel Risk Assessment Form

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Please be aware that we require at least 8 weeks notice before you travel to allow time for your vaccinations to be ordered in and given in time to be effective for your holiday.

Last Updated: 19/04/2023

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

Gender *

Male

Female

Trip Details

Departure Date *

Trip duration *

Please give details of country/countries to be visited, length of stay and how remote you will be from medical help *

Trip Description

Purpose of Trip *

Business

Pleasure

Other

Voluntary Work

Healthcare worker

Type of Trip *

Package

Self-Organised

Backpacking

Camping

Cruise Ship

Trekking

Holiday

Business Trip

Expatriate

Volunteering

Healthcare Worker

Diving

Adventure

Medical Tourism

Pilgrimage

Safari

Accommodation *

Hotel

Friends/Family

Other

Travelling *

Alone

With Friends/Family

In a Group

Location Type *

Urban

Rural

Altitude

Personal Medical History

List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions) *

Are you fit and well ? *

Do you have an immune system condition? *

Yes No

Do you have HIV/AIDS? *

Yes No

Do you have have any of the following? *

Aneamia

Bleeding and clotting disorder

History of DVT

Heart Disease eg angina or high blood pressure

epilepsy

Gastrointestinal (stomach) complaints

Liver /Kidney problems

Neurological problems

Respiratory lung disease

rheumatology joint conditions

spleen problems

any other conditions

List all allergies that you have (eg. eggs, nuts, antibiotics, latex etc) *

If you have had a serious reaction to a vaccine in the past, which vaccine was it? *

List all of your current medications (including oral contraception) *

Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)? *

Yes No

Does having an injection cause you to feel faint? *

Yes No

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

Yes No

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

Yes No

Have you taken out travel insurance? *

Yes No

If you have a medical condition, have you told your insurance company about it? *

Yes No

Are you pregnant, planning pregnancy or breast feeding? *

Yes No

Write below any further information that might be relevant *

Vaccination History

Have you ever had any of the following vaccinations / tablets and if so, when? *

Tetanus

Polio

Diptheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Japanese B Enceph

Tick Borne

Malaria

Cholera

MMR

BCG

Pneumococcal

Other

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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Further Information

Travel Health
Veterans
Domestic Abuse
GDPR and Privacy
GP Earnings
Practice Charter
Practice Policies
Suggestions & Complaints

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