Travel Risk Assessment Form

Full Name *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address:

Gender:

Male

Female

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

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

Are you pregnant or planning pregnancy or breast feeding?

Please write below any further information which may be relevant:

Which year did you have the Tetanus vaccination? *

Which year did you have the Polio vaccination? *

Which year did you have the Hepatitis A vaccination? *

Which year did you have the Hepatitis B vaccination? *

Which year did you have the Meningitis vaccination? *

Which year did you have the Yellow Fever vaccination? *

Which year did you have the Influenza vaccination? *

Which year did you have the Rabies vaccination? *

Which year did you have the Jap B Enceph vaccination? *

Which year did you have the Tick Bourne vaccination? *

Which year did you have the Diptheria vaccination? *

Which year did you have the Typhoid vaccination? *

If 'Other / Malaria tablets' please list here: *

Which year did you have the other vaccination / malaria tablets? *

Signed: *

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

Date:

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Online Services

Travel Clinic

Meet the Team

Receptionist Yasmin Qalib

Receptionist Marian Jalloh

Senior Receptionist Gladys Enninful

General Practitioner Dr. Nazeer Ahmed

Services

Policies

Monday	9:00am – 8:00pm
Tuesday	9:00am – 8:30pm
Wednesday	9:00am – 8:30pm
Thursday	9:00am – 6:30pm
Friday	9:00am – 6.30pm

	On the day	Patients can book an appointment on the day from 9:00am by calling 020 8964 9990 or by calling into the practice.
	Commuter Surgeries	Not able to see the doctor outside of working hours? Late surgeries are available by pre-booked appointment to see the Doctor or Practice Nurse.
	Telephone Consultations	For help and advice, call us on 020 8964 9990.
	Nurse Appointments	The Practice Nurses can help you with a range of issues from health management to vaccinations.
	Book in Advance	We reserve a few appointments for advance booking. Please phone the practice on 020 8964 9990 for more information.
	Out of Hours	If you have an urgent health problem which cannot wait until the surgery is open please call 111.
	Online Services	Patients can book appointments up to 2 weeks in advance and from 8pm the night before using our online booking system.

	Online	You can order your repeat prescriptions via our online services or using our online form.
	In Person	Fill in a prescription request form or underline the items needed on the tear-off side of your prescription and drop it into the surgery.
	Post	If a stamped addressed envelope is supplied your prescription can be returned via Royal Mail. Find our postal address.
	Fax	Fax your prescription request to 020 8964 0436.
	Pharmacy	You may also arrange for a pharmacy of your choice to collect your prescription on your behalf