Pre Travel Assessment Form - The Crown Medical Centre

If you are travelling and require vaccinations, please complete the below travel form and either email or hand into reception. The nurses will review the form and arrange appropriate appointments and order vaccinations as required.

Please note that we require at least 8 weeks' notice before travelling so if your trip is going to be within the next 8 weeks please contact one of the clinics listed below.

Personal details:

Patient Name

Date of birth

Contact Number

Email address

Travel details:

Destination of travel

Date of travel

Journey Purpose

Travelling with?

If other, please specify

Will you be in transit in any country before reaching your destination for 12 hours or more

If yes, please specify: the country, arrival date, and length of stay

Medical history:

Do you have any of the following?

Any history of respiratory illness? Eg. Asthma/COPD

Any history of heart disease or high blood pressure?

Any history of diabetes or epilepsy?

Any history of gastro-intestinal illness, liver or kidney disease?

Any history of chemotherapy, radiotherapy or steroid treatment?

Any history of immunosuppression e.g. thymus disorder or HIV/AIDS?

Any history of mental health (psychiatric) illness e.g. depression?

Are you breastfeeding, pregnant or planning a pregnancy?

None of the above

Do you have any allergies? If yes, please list

Are you taking any medication? Prescribed or other? If yes, please list

Do you have any significant medical history not mentioned above? If yes, please state

Consent:

Please print name

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

I consent to my information being used for the purposes described above and wish to submit this online form to The Crown Medical Centre • Venture Way, Taunton, TA2 8QY.

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