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Travel Risk Assessment

Please complete the online form below before your appointment.  Alternatively click here to download the form, return the completed form to the surgery before your appointment.

 

1Travel Risk Assessment

2Please supply information about your trip

3Please supply details of your personal medical history

Women only

For everyone

4Please supply information on any vaccines or malaria tablets taken in the past

If you have had any of the vaccinations or malaria tablets referred to below please provide details.

5Any additional information

Travel risk assessment form devised by Jane Chiodini © 2012 in conjunction with resources below. 1. Chiodini J, Boyne L, Grieve S, Jordan A. (2007) Competencies: An Integrated Career and Competency Framework for Nurses in Travel Health Medicine. RCN, London. www.rcn.org.uk 2. Field VK, Ford L, Hill DR, eds. (2010) Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK. Form devised and created by Jane Chiodini © updated 2017

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Little Bushey Surgery, California Lane, Bushey, Herts, WD23 1EZ
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Your Neighbourhood Professionals. Just a Click Away! Need care but want to stay in your own home?
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