Travel Risk Assessment

 
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Check that date of departure is correct -  as we need the minimum of 6 weeks to be able to arrange appropriate appointments and vaccinations.

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Trip Details
Holiday Type: *
Type of Trip: *
Accommodation: *
Travelling: *
Staying in area which is: *
Planned Activities: *
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Personal Details
Please double check you've entered the correct email address
Gender: *
May be used to identify you
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Personal Medical History
Including diabetes, heart or lung conditions
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?:
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?:
Have you ever had any of the following vaccinations / malaria tablets?:
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Signed & Dated
Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Care Quality Commission
Overall Rating: Good

Kent House Surgery
36 Station Road
Longfield
Kent
DA3 7QD

Telephone: 01474 702 127

New Ash Green Surgery
New Ash Green
Longfield
Kent
DA3 8RH

Telephone: 01474 873 828

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