This site uses cookies for analytics and to improve your experience. By clicking Accept, you consent to our use of cookies.

Skip to content

Mawney Road Surgery

206 Mawney Road | Romford | Essex | RM7 8BU | Tel: 01708 739 379

Main Menu

Home
- Friends and Family Test
- Friends and Family Test Results
About Us
Appointments
Clinical Services
Help and Support
Our News

Travel Risk Assessment Form

Travel Risk Assessment Form

Personal Information

Name *

First

Last

Date of Birth *

Your Country of Origin

Your Gender

Telephone / Mobile Numbers

Email *

Email

Confirm Email

Please supply information about your trip in the sections below:

Date of Departure *

Date of Return *

Please list the countries you are visiting, their exact location or region, city or rural and length of stay

Please list as follows e.g.: Africa / Kenya / City / 21 days

Type of travel and purpose of trip

Type of Trip *

Business
Pleasure
Other

Type of Holiday *

Package
Self Organised
Backpacking
Camping
Cruise Ship
Trekking

Accommodation *

Hotel
Staying with Relative/Friends
Family Home
Other

Who are you Travelling with? *

Alone
With family/friends
In a Group

Which area are you staying *

Urban
Rural
Altitude

Planned Activities *

Safari
Adventure
Other

Please provide any further information in the box below:

Details of Your Medical History

Do you have any recent or past medical history of note? (including 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? *

Yes
No
Don't know

Please give details of the type of reaction you had:

Do you have a tendancy to faint with injections? *

Yes
No
Don't know

Please give details of what made you faint, e.g. seeing the needle:

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

Please give details, e.g. radiotherapy: *

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

Yes
No
Don't know

Please give details of travel insurance:

Please type below any further information which may be relevant:

Vaccination Details

Have you ever had any of the following vaccinations / malaria tablets? *

Tetanus
Polio
Diphtheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick borne encephalitis
Other
Malaria Tablets

Please provide any details if you can of all that you ticked above

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Consent *

I consent to the practice collecting and storing my data from this form.

Travel risk assessment form devised by Jane Chiodini © 2012 in conjunction with resources below.

Chiodini J, Boyne L, Grieve S, Jordan A. (2007) Competencies: An Integrated Career and Competency Framework for Nurses in Travel Health Medicine. RCN, London.
Field VK, Ford L, Hill DR, eds. (2010) Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK

Health A-Z

NHS Guide to conditions, symptoms & treatments

Live Well

Advice, tips and tools for health & wellbeing

Medicines Guide

How medicine works & possible side effects

Care and Support

Options & where to get the best support

Services directory

Mawney Road Surgery

206 Mawney Road
Romford
Essex
RM7 8BU
Get Directions
01708 739 379
[email protected]

Surgery Hours

Monday 08:00 - 18:30

Tuesday 08:00 - 18:30

Wednesday 08:00 - 18:30

Thursday 08:00 - 18:30

Friday 08:00 - 18:30

Saturday Closed

Sunday Closed

Out of Hours NHS 111

Quick Links

Main Menu

Care Quality Commission
Contact Us
Friends and Family Test
Useful Contacts
Your Practice Charter

Main Menu

Accessibility Statement
Disclaimer

© 2015-2026 Mawney Road Surgery

Web Design by Webicious UK Ltd

Scroll to Top

Insert/edit link

Enter the destination URL

URL

Link Text

Open link in a new tab

Or link to existing content

Search

No search term specified. Showing recent items. Search or use up and down arrow keys to select an item.

Skip to content

Accessibility Tools

Increase Text
Decrease Text
Grayscale
High Contrast
Negative Contrast
Light Background
Links Underline
Readable Font
Reset