Travel Risk Assessment Form

Before you start:

The information you provide in this form will be processed by Cedar Practice. The information will be treated as confidential and stored in a secure data centre located in the UK. The information will be uploaded to your record in the practice’s clinical system as soon as possible after submission, after which the copy of your information in the data centre will be securely destroyed.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of providing this information.

The information you provide will be processed with the sole purpose of providing you with Direct Care within the surgery and in support of Direct Care elsewhere. Our Privacy Policy provides further detail about how we process your personal information for the purposes of Direct Care.

You have the right to revoke this Consent to the terms laid here, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.

Consent(Required)

I confirm I have read and agree to the above terms.

Consent(Required)

I confirm that the information I will provide in this form will be true and accurate, to the best of my knowledge.

This is a travel risk assessment form. Only complete this form if directed to by a member of practice staff.

Please fill in this form to the best of your ability. You must complete and submit this form prior to any appointment you have at the practice regarding this episode of travel.

Cedar Practice is only able to provide NHS vaccinations: Diptheria, Tetanus and Polio, Hepatitis A and Typhoid. You will be referred on to a private clinic if it is thought that you need any other vaccinations.

Name(Required)

First Last

Date of birth(Required)

DD slash MM slash YYYY

Gender(Required)

Male

Female

Non-binary

Telephone number(Required)

Email address

Your country of origin

Please supply information about your trip in the sections below

Date of departure(Required)

DD slash MM slash YYYY

Total length of trip (in days)(Required)

Country to be visited (1)(Required)

Exact location(s) or region(s)(Required)

City or rural(Required)

City

Rural

Both

For how long are you staying here? (in days)(Required)

Are you travelling to more than one country on this trip?(Required)

Yes

Information about second country

Date of departure(Required)

DD slash MM slash YYYY

Country to be visited (2)(Required)

Exact location(s) or region(s)(Required)

City or rural(Required)

City

Rural

Both

For how long are you staying here? (in days)(Required)

Are you travelling to any further countries on this trip?(Required)

Yes

Information about third country

Date of departure(Required)

DD slash MM slash YYYY

Country to be visited (3)(Required)

Exact location(s) or region(s)(Required)

City or rural(Required)

City

Rural

Both

For how long are you staying here? (in days)(Required)

What modes of transport will you be using?(Required)

Have you taken out travel insurance for this trip?(Required)

Yes

Do you plan to travel abroad again in the future?(Required)

Yes

Type of travel and purpose of trip - please tick all that apply(Required)

Holiday

Business trip

Expatriate

Volunteer work

Healthcare worker

Staying in hotel

Cruise ship trip

Safari

Pilgrimage

Medical tourism

Backpacking

Camping / hostels

Adventure

Diving

Visiting friends / family

Please supply details of your personal medical history

Are you currently fit and well?(Required)

Yes

Any allergies including food, latex, medication?(Required)

Yes

Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?(Required)

Yes

Do you have a tendency to faint with injections?(Required)

Yes

Any surgical operations in the past, including e.g. open heart surgery, spleen or thymus gland removal?(Required)

Yes

Any recent chemotherapy/radiotherapy/organ transplant?(Required)

Yes

Do you have anaemia?(Required)

Yes

Do you have a bleeding / clotting disorder (including a history of DVT)?(Required)

Yes

Do you have cardiovascular disease (e.g. angina, high blood pressure)?(Required)

Yes

Do you have diabetes?(Required)

Yes

Do you have additional needs and/or a disability?(Required)

Yes

Do you have epilepsy/seizures (or in a first degree relative)?(Required)

Yes

Do you have gastrointestinal (stomach) complaints?(Required)

Yes

Do you have liver and/or kidney problems?(Required)

Yes

Do you have HIV/AIDS?(Required)

Yes

Do you have an immune system condition (e.g. blood cancer)?(Required)

Yes

Do you have mental health issues (including anxiety, depression)?(Required)

Yes

Do you have a neurological (nervous system) illness?(Required)

Yes

Do you have a respiratory (lung) disease (e.g. asthma, COPD)?(Required)

Yes

Do you have rheumatology (joint) conditions?(Required)

Yes

Do you have any spleen problems?(Required)

Yes

Do you have any other conditions?(Required)

Yes

Are you or your partner pregnant or planning a pregnancy?(Required)

Yes

Are you breastfeeding?(Required)

Yes

Not applicable

Have you or anyone in your family undergone FGM / been cut / circumcised?(Required)

Yes

Please provide details if you have selected "Yes" to any of the above

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?(Required)

Yes

Please list your current medication(Required)

Have you had any of these vaccines, or taken malaria tablets in the past?(Required)

Please select all that apply

Tetanus/polio/diptheria

Typhoid

Cholera

Rabies

Yellow fever

MMR

Hepatitis A

Hepatitis B

Japanese encephalitis

BCG

Influenza

Pneumococcal

Meningitis

Tick-borne encephalitis

Covid-19

Malaria tablets

Please provide additional information if you have selected any of the above, such as the date it was administered, the manufacturer of the vaccine (if known)