Travel Risk Assessment Form

Please complete the form prior to travel. Once the form is received by the practice a nurse will review the information and contact you.

Name

Date of Birth

Home Telephone

Mobile Number

Date of Departure

Total Length of Trip

Personal Medical History

Are You Fit And Well Today?

Any Allergies

Please List Details of Allergies

Any Severe Reactions To A Vaccine Before?

Please List Details Of Any Severe Reactions To Previous Vaccinations

Any Surgical Operations In The Past?

Any Recent Chemotherapy / Radiotherapy / Organ Transplant

Any Bleeding / Clotting Disorders Including A History of DVT?

Any Heart Disease e.g angina, high blood pressure?

WOMEN ONLY

Are You Pregnant?

Are You Breast Feeding?

Are You Planning Pregnancy While Away?

Any Addtional Information

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Solent View Medical Practice • Lee-on-the-Solent Health Centre, Manor Way, Lee-on-the-Solent , Hampshire , PO13 9JG.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.