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Home
My Care
Women’s Health Hub
Men’s Health
Children
Keeping Well Campaign
COVID-19 Information
Patient Information Resources
Third Party Consent Form
Referrals
Physiotherapy Self Referral
Podiatry Self-Referral
Immunisations
Covid and Flu Vaccinations 2023/24
Cardiovascular Risk
Mental Health
Beacon Musculoskeletal Service
Patient Living Out Of Area
Social Prescribing
Travel Abroad
Supply of Medication for Patients Travelling Abroad
Youth Centre
Community referrals to local pharmacy
Why have I been invited for a blood pressure check?
Medication Changes
Changes to Codeine Prescribing
My Appointment
Make an Appointment
Order Medication
Meet the Doctors
Surgeries
Chaddlewood Surgery
Glenside Medical Centre
Highlands Health Centre
Ivybridge Medical Practice
Plympton Health Centre
Wotter Surgery
My Record
My Record
Change Address
Carers
New Patient Registration
Registering for Care Homes
Proxy Access Form
Subject Access Requests
Online Services Registration
Further access from the NHS APP request
Privacy Policy
Summary Care Record (Opt out)
Opt Out Type 1
Non NHS fees
About Us
Our Team
Primary Care Network
Beacon Newsletter
Our History
Research
Latest News
Patient Participation Group
Friends and Family
Freedom of Information
Our Services
Careers and Recruitment
Contact
Travel Risk Assessment Form
Step
1
of
4
25%
Name
(Required)
First
Last
Date of Birth
(Required)
DD slash MM slash YYYY
Sex
(Required)
Male
Female
Email
(Required)
Contact number
(Required)
Date of Departure
(Required)
DD slash MM slash YYYY
Total Length of Trip
(Required)
(Required)
Country to be visited
Exact Location or Region
City
Length of visit
Have you taken out travel insurance for this trip?
(Required)
Yes
No
Purpose of Travel
(Required)
Holiday
Staying in hotel
Backpacking
Business Trip
Cruise ship trip
Camping/hostels
Expatriate
Safari
Adventure
Volunteer work
Pilgrimage
Diving
Healthcare worker
Medical tourism
Visiting friends/family
Are you fit and well today
(Required)
Yes
No
Any allergies including food, latex, medication
(Required)
Yes
No
Severe reaction to a vaccine before
(Required)
Yes
No
Tendency to faint with injections
(Required)
Yes
No
Any surgical operations in the past, including e.g. your spleen or thymus gland removed
(Required)
Yes
No
Recent chemotherapy/radiotherapy/organ transplant
(Required)
Yes
No
Anaemia
(Required)
Yes
No
Bleeding/clotting disorders (including history of DVT)
(Required)
Yes
No
Heart disease (e.g. angina, high blood pressure)
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Disability
(Required)
Yes
No
Epilepsy/seizures
(Required)
Yes
No
Gastrointestinal (stomach) complaints
(Required)
Yes
No
Liver and or kidney problems
(Required)
Yes
No
HIV/AIDS
(Required)
Yes
No
Immune system condition
(Required)
Yes
No
Mental health issues (including anxiety, depression)
(Required)
Yes
No
Neurological (nervous system) illness
(Required)
Yes
No
Respiratory (lung) disease
(Required)
Yes
No
Rheumatology (joint) conditions
(Required)
Yes
No
Spleen problems
(Required)
Yes
No
Any other conditions?
(Required)
Yes
No
Are you pregnant? (Women only)
Yes
No
Are you breast feeding? (Women only)
Yes
No
Are you planning pregnancy while away? (Women only)
Yes
No
Give more details for any of the above
Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?
Please supply information on any vaccines or malaria tables taken in the past
BCG
Cholera
Hepatitis A
Hepatitis B
Influenza
Japanese Encephalitis
Malaria Tablets
Meningitis
MMR
Pneumococcal
Rabies
Tetanus/polio/diphtheria
Tick Borne Encephalitis
Typhoid
Yellow fever
Other
Additional vaccine information