Shepherds Spring Medical Centre

Travel Risk Assessment Form

Travel Risk Assessment
Please use format day/month/year e.g. 12/05/1979
Please use format day/month/year e.g. 12/05/2019

Details of country to be visited

Add all countries you will be visiting on your trip.
Area type
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip
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?
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised
Are you currently taking any medication?

Have you taken any vaccines or malaria tablets in the past?

Tetanus/polio/diphtheria
Typhoid
Cholera
Rabies
Yellow fever
MMR
Hepatitis A
Hepatitis B
Japanese encephalitis
BCG
Influenza
Pneumococcal
Tick borne encephalitis
Tick borne encephalitis
COVID-19
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.