Billingshurst Surgery Travel Risk Assessment Form
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2Billingshurst Surgery Travel Risk Assessment Form
Please complete this form prior to your travel and return it to reception. You will be phoned to arrange an
appointment.
Personal details
Name:
_____________________________________________________________________________________________________
Date of Birth:
Male [ ]
Female [ ]
_____________________________________________________________________________________________________
Easiest contact telephone number:
E.mail:
_____________________________________________________________________________________________________
Dates of trip
Date of departure:
Return date or overall length of trip:
Itinerary and purpose of visit
Country to be visited
Length of stay
Away from medical help at destination?
If so, how remote?
_____________________________________________________________________________________________________
1.
_____________________________________________________________________________________________________
2.
_____________________________________________________________________________________________________
3.
_____________________________________________________________________________________________________
Please circle the descriptions that best describe your trip
1.
Type of trip:
Business
Pleasure
Other
_____________________________________________________________________________________________________
2.
Holiday type:
Package
Self-organised
Backpacking
Camping
Cruise ship
Trekking
_____________________________________________________________________________________________________
3.
Accommodation:
Hotel
Relatives/family home
Other
_____________________________________________________________________________________________________
4.
Travelling:
Alone
With family/friend
In a group
_____________________________________________________________________________________________________
5.
Staying in area which is:
Urban
Rural
Altitude
_____________________________________________________________________________________________________
6.
Planned activities:
Safari
Adventure
Other
_____________________________________________________________________________________________________
Personal medical history
Do you have any recent or past medical history of note? This includes diabetes, heart or lung conditions.
_____________________________________________________________________________________________________
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?
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Parent category: Business