Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Skip to main content

Wadebridge and Camel Estuary Practice NHS GP Surgery in Cornwall

Travel risk assessment

Travel Risk Assessment

Sex:

Male

Female

Indeterminate

Dates of Trip

Date of Departure:

Please use this date format: DD/MM/YYYY

Return date or overall length of trip:

Please use this date format: DD/MM/YYYY

Itinerary and Purpose of Visit

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

Personal Medical History

Do you have any recent or past medical history of note?

Including diabetes, heart or lung conditions, thymus disorder

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?

Does having an injection make you feel faint?

Do you or any close family members have epilepsy?

Do you have any history or mental illness including depression or anxiety?

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Are you pregnant or planning pregnancy or breast feeding?

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about his?

Please write below any further information which may be relevant:

Vaccincation History

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: *

Malaria tablets: *

Other 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.

Brooklyn
Wadebridge
Cornwall
PL27 7BS

Get directions

01208 812 222

About the surgery

Register with the surgery

Sick (fit) notes

Feedback and complaints

© Silicon Practice

Accessibility statement

Website policies