Sawston Medical Centre, Linton Health Centre, Market Hill Surgery, Barley Surgery, Shelford Health Centre & Royston Health Centre.

Travel Risk Assessment Form

To be completed by traveller prior to appointment

Name

Date of Birth

Gender

Male Female Other

Address

Preferred Contact Number

Can we leave a message?

Yes No

Acceptance

I accept the website terms & conditions

View the terms & conditions (opens in a new browser tab)

About your trip

Date of departure

Total length of trip

Have you taken out travel insurance for this trip?

Yes No

Do you plan to travel abroad again in the future?

Yes No

Country 1 to be visited

Exact location or region

City or rural

City Rural

Length of stay

Country 2 to be visited

Exact location or region

City or rural

City Rural

Length of stay

Country 3 to be visited

Exact location or region

City or rural

City Rural

Length of stay

Type of travel and purpose of trip

Additional information

Personal medical history details

What is your smoking status?

Never smoked Smoker Ex-smoker

Are you fit and well?

Yes No

Details

Do you have and allergies, inc. food, latex, medication?

Yes No

Details

Have you previously experienced a severe reaction to a vaccine?

Yes No

Details

Do you have a tendency to faint with injections?

Yes No

Details

Have you had any surgical operations in the past?

Yes No

Details

Have you had your thymus gland removed?

Yes No

Details

Have you recently had chemotherapy or radiotherapy?

Yes No

Details

Have you had an organ transplant?

Yes No

Details

Do you suffer from anaemia?

Yes No

Details

Do you have any bleeding or clotting disorders, for example, a history of DVT?

Yes No

Details

Do you have heart disease, eg. angina, high blood pressure?

Yes No

Details

Do you have (please tick as appropriate)

Diabetes

Yes No

Details

Disability

Yes No

Details

Epilepsy or seizures

Yes No

Details

Gastrointestinal (stomach) complaints

Yes No

Details

Liver and or kidney problems

Yes No

Details

HIV / AIDS

Yes No

Details

Immune system condition

Yes No

Details

Mental health issues (inc. anxiety, depression)

Yes No

Details

Neurological (nervous system) illness

Yes No

Details

Respiratory (lung) disease

Yes No

Details

Rheumatology (joint) conditions

Yes No

Details

Spleen problems

Yes No

Details

Any other conditions?

Yes No

Details

Women only

Are you pregnant?

Yes No

Details

Are you breast feeding?

Yes No

Details

Are you planning pregnancy whilst away?

Yes No

Details

Are you currently taking any medication (including prescribed, purchased or contraceptive pill)?

Yes No

Details

Have you had any of the following vaccines / tablets in the past?

Any additional information

Sawston Medical Centre
London Road
Sawston
Cambridge CB22 3HU

Appointments:
0300 234 5555
option 2

Linton Health Centre
Coles Lane
Linton
Cambridge CB21 4JS

Appointments:
0300 234 5555
option 3

Barley Surgery
High Street, Barley
Royston
Hertfordshire SG8 8HY

Appointments:
0300 234 5555
option 4

Market Hill Surgery
Market Hill
Royston
Hertfordshire SG8 9JN

Appointments:
0300 234 5555
option 5

Shelford Health Centre
Ashen Green
Great Shelford
Cambridge CB22 5FY

Appointments:
0300 234 5555
option 6

Royston Health Centre
Melbourn Street
Royston
Hertfordshire SG8 7BS

Appointments:
0300 234 5555
option 7

Sawston Medical Centre
London Road, Sawston, Cambridge
CB22 3HU
Appointments: 0300 234 5555 option 2

Linton Health Centre
Coles Lane, Linton, Cambridge
CB21 4JS
Appointments: 0300 234 5555 option 3

Barley Surgery
High Street, Barley, Royston, Hertfordshire
SG8 8HY
Appointments: 0300 234 5555 option 4

Market Hill Surgery
Market Hill, Royston, Hertfordshire
SG8 9JN
Appointments: 0300 234 5555 option 5

Shelford Health Centre
Ashen Green, Great Shelford, Cambridge
CB22 5FY
Appointments: 0300 234 5555 option 6

Travel Risk Assessment Form

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