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

Magdalen Medical Practice NHS GP Surgery in Norwich

Travel risk assessment

Travel Risk Assessment

Section

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

Country to be visited:

Where in the country:

Length of stay:

How remote will you 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

Please list any other planned activities:

List any recent or past medical history of note:

Including diabetes, heart or lung conditions

List any current or repeat medications:

List any allergies:

Have you ever had a serious reaction to a vaccine given to you before?

Yes

No

Don’t Know

Does having an injection make you feel faint?

Yes

No

Don’t Know

Do you or any close family members have epilepsy?

Yes

No

Don’t Know

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

Yes

No

Don’t Know

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Don’t Know

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

Yes

No

Don’t Know

Are you pregnant or planning pregnancy or breast feeding?

Please write below any further information which may be relevant:

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: *

Other / Malaria tablets please list here: *

Additional Questions

Will you be having a stopover? *

Yes

No

Smoking

Smoking Status: *

Current Smoker

Ex Smoker

Never Smoked

How many do you smoke per day?

Are you interested in advice on how to quit?

Yes

No

How many did you smoke per day?

When did you stop?

Signed: *

Date:

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent.

If you are human, leave this field blank.

Magdalen Medical Practice
Lawson Road
Norwich
Norfolk
NR3 4LF

Get directions

01603 475555

About the surgery

Register with the surgery

Sick (fit) notes

Feedback and complaints

© Silicon Practice

Accessibility statement

Website policies