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Springfield Medical Centre NHS GP Surgery in Eccles

Travel risk assessment

Travel Risk Assessment

*

Confirmation of consent for information about your/the patient’s health to be sent to the email address provided

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:

Holiday type:

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

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

List any recent or past medical history of note:

Including diabetes, heart or lung conditions

List any current or repeat medications:

List any allergies:

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

Are you pregnant or planning pregnancy or breast feeding?

Please write 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 Enceph (TBE):

Other / Malaria tablets

Please state which year you had the vaccination(s):

Tetanus: *

Polio: *

Hepatitis A: *

Hepatitis B: *

Meningitis: *

Yellow Fever: *

Influenza: *

Rabies: *

Jap B Enceph: *

Tick-borne Enceph (TBE): *

Diptheria: *

Typhoid: *

Other / Malaria tablets please list here: *

Signed: *

Date:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent – it may take up to 2 working days before I receive a reply.

If you are human, leave this field blank.

384 Liverpool Road
Eccles
Manchester
M30 8QD

Get directions

0161 871 2450

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