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AW Surgeries NHS GP Surgery in Brierley Hill

Travel risk assessment

Travel Risk Assessment

Required fields are labelled

You must be aged 13 or over to complete this form yourself

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

Date of Departure:

Please use this date format: DD/MM/YYYY

Return Date:

Please use this date format: DD/MM/YYYY

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

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: Required

Polio: Required

Hepatitis A: Required

Hepatitis B: Required

Meningitis: Required

Yellow Fever: Required

Influenza: Required

Rabies: Required

Jap B Enceph: Required

Tick-borne Enceph (TBE): Required

Diptheria: Required

Typhoid: Required

Other / Malaria tablets please list here: Required

Signed: Required

Date:

Confirmation Required

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.

The Surgery is now closed

The Practice is now closed.

If your enquiry is urgent please contact NHS 111 or alternatively you can use the Pharmacy First Service for treating minor ailments and seeking advice. You can also visit our online treatment room for self help on physical health care requests or our online wellbeing centre for information regarding mental health services. If your enquiry is not urgent then please revisit our website from 8.00am until 6.30pm, Monday to Friday.

Albion House
Albion Street
Brierley Hill
West Midlands
DY5 3EE

Get directions

01384 465422

Withymoor Surgery
Squires Court
Brierley Hill
West Midlands
DY5 3RJ

Get directions

01384 465422