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Download Dr. iQ - our practice mobile app

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Access Dr. iQ our practice mobile app

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Dr. iQ is our practice mobile app. For the fastest, most convenient way to access our GP services,
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Travel Risk Assessment Form


Travel Risk Assessment Form

Get advice about travelling abroad, including the latest on safety, security and travel warnings: Find out more.

Please complete the form below. Once completed you will need to book two consecutive appointments (i.e. two appointments together) with one of our practice nurses.

You can book your appointment online via Dr. iQ

We recommend that you attended your appointments 8 weeks before you leave for your holiday.

Travel risk assessment form
Please select the gender that you most identify with.

Please supply information about your trip in the sections below

Type of travel and purpose of trip - please tick all that apply

Please supply details of your personal medical history

Are you fit and well today
Any allergies including food, latex, medication
Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before?
Tendency to faint with injections
Any surgical operations in the past, including e.g. open heart surgery, spleen or thymus gland removal?
Recent chemotherapy/radiotherapy/organ transplant
Bleeding /clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Additional needs and/or disability
Epilepsy/seizures (or in a first degree relative?)
Gastrointestinal (stomach) complaints
Liver and or kidney problems
Immune system condition e.g. blood cancer
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions?
Are you or your partner pregnant or planning a pregnancy?
Are you breast feeding (if applicable)
Have you or anyone in your family undergone FGM / been cut / circumcised