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Menu
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About Us
Contact
Have your Say
Making the most of your Practice
Meet the Team
Doctors
Pharmacists
Nurses
Practice Team
Our Allied Health Professionals
Practice Policies
At the Practice
Patients Moving Abroad
Data
Patient Record
Patient Rights
Website
Hospital Prescriptions
Regulations & Governance
Teenage Friendly
Behind the Scenes of a General Practice Surgery
Clinics & Services
Appointments, Tests & Referrals
Appointments
Flu Season
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
The getUbetter App – Musculoskeletal Help
Out of Hours Service
Online Services
Patient Record
Online Access to Medical Records
Learn My Way
NHS App
Proxy Access
Practice Services
Travel Clinic & Holiday Vaccinations
Community Pharmacy Referral Pathway (CPCS)
Forms
Keep us up to Date
Health Review Forms
Help & Support
News
Need help with a non-urgent medical or admin request? Contact us online.
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Wrythe Green Surgery
>
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Health Review Forms
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Travel Risk Assessment Form
Travel Risk Assessment Form
Travel Risk Assessment
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
Holiday type
*
Package
Self organised
Backpacking
Camping
Cruise ship
Trekking
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
No
Don’t Know
Does having an injection make you feel faint?
*
Yes
No
Don’t Know
Do you or any close family members have epilepsy?
*
Yes
No
Don’t Know
Do you have any history or mental illness including depression or anxiety?
*
Yes
No
Don’t Know
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
*
Yes
No
Don’t Know
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
*
Yes
No
Don’t Know
Please type below any further information which may be relevant:
Have you ever had any of the following vaccinations / malaria tablets?
*
Tetanus
Polio
Diptheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Other / Malaria tablets
Privacy Policy
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.
Your consent
*
I consent to the practice collecting and storing my data from this form.
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Home
About Us
Contact
Have your Say
Making the most of your Practice
Meet the Team
Doctors
Pharmacists
Nurses
Practice Team
Our Allied Health Professionals
Practice Policies
At the Practice
Patients Moving Abroad
Data
Patient Record
Patient Rights
Website
Hospital Prescriptions
Regulations & Governance
Teenage Friendly
Behind the Scenes of a General Practice Surgery
Clinics & Services
Appointments, Tests & Referrals
Appointments
Flu Season
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
The getUbetter App – Musculoskeletal Help
Out of Hours Service
Online Services
Patient Record
Online Access to Medical Records
Learn My Way
NHS App
Proxy Access
Practice Services
Travel Clinic & Holiday Vaccinations
Community Pharmacy Referral Pathway (CPCS)
Forms
Keep us up to Date
Health Review Forms
Help & Support
News