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New Court Surgery NHS GP surgery in Royal Wootton Bassett

Travel risk assessment

Travel risk assessment

What is your country of origin? *

What is your date of departure? *

For example, 15 3 1984

What is your return date? *

For example, 15 3 1984

Tell us about your trip *

Include which countries you are visiting, the exact location or region, city or rural, and the length of stay in each location

Which modes of transport will you be using? *

Have you taken out travel insurance for this trip? *

Yes

No

Do you plan to travel abroad again in the future? *

Yes

No

What is the type and purpose your trip?

Adventure

Backpacking

Business trip

Camping or staying in a hostel

Cruise ship trip

Diving

Expatriate

Healthcare worker

Holiday

Medical tourism

Pilgrimage

Safari

Staying in hotel

Visiting friends or family

Volunteer work

Other additional information

Provide any additional information *

Are you fit and well today? *

Yes

No

Provide details about how you are not fit and well *

Do you have any allergies? *

For example, food, latex, medication

Yes

No

Provide details about any allergies *

Have you or anyone in your family ever had a severe reaction to a vaccine or malaria medication? *

Yes

No

Provide details about any severe reactions that you have had *

Do you have a tendency to faint with injections? *

Yes

No

Provide details about your tendency to faint with injections *

Have you had any surgical operations in the past? *

For example, open heart surgery, your spleen or thymus gland removed

Yes

No

Provide details about any surgical operations you have had *

Have you recently undergone chemotherapy, radiotherapy or had an organ transplant? *

Yes

No

Provide details about the chemotherapy, radiotherapy or organ transplant *

Do you have anaemia? *

Yes

No

Provide details about your anaemia *

Do you have any bleeding or clotting disorders? *

For example, a history of DVT

Yes

No

Provide details about your bleeding or clotting disorders *

Do you have a heart disease? *

For example, angina, high blood pressure

Yes

No

Provide details about your heart disease *

Do you have diabetes? *

Yes

No

Provide details about your diabetes *

Do you have any additional needs or disabilities? *

Yes

No

Provide details about your additional needs or disabilities *

Do you or a first degree relative have epilepsy or seizures? *

Yes

No

Provide details about the epilepsy or seizures *

Do you have gastrointestinal complaints? *

Problems with your stomach

Yes

No

Provide details about your gastrointestinal complaints *

Do you have liver and or kidney problems? *

Yes

No

Provide details about your liver and or kidney problems *

Do you have HIV or AIDS? *

Yes

No

Provide details about your HIV or AIDS *

Do you have an immune system condition? *

For example, blood cancer

Yes

No

Provide details about your immune system condition *

Do you have any mental health issues? *

For example, anxiety, depression

Yes

No

Provide details about your mental health issues *

Do you have a neurological illness? *

Problems with your nervous system

Yes

No

Provide details about your neurological illness *

Do you have a respiratory disease? *

Problems with your lungs

Yes

No

Provide details about your respiratory disease *

Do you have any rheumatology conditions? *

Problems with your joints

Yes

No

Provide details about your rheumatology conditions *

Do you have any spleen problems? *

Yes

No

Provide details about your spleen problems *

Do you have any other conditions? *

Yes

No

Provide details about any other conditions *

Are you or your partner pregnant are planning a pregnancy? *

Yes

No

Not applicable

Provide details about the pregnancy *

Are you breastfeeding? *

Yes

No

Not applicable

Provide details about your breastfeeding *

Have you or anyone in your family undergone FGM, been cut or circumcised? *

Yes

No

Not applicable

Provide details about the FGM, been cut or circumcised *

Are you currently taking any medication? *

For example, prescribed, purchased or a contraceptive pill

Yes

No

Provide details about the medications you are taking *

Which vaccinations or tablets have you had in the past?

BCG

Cholera

COVID-19

Hepatitis A

Hepatitis B

Influenza

Japanese encephalitis

Malaria tablets

Meningitis

MMR

Pneumococcal

Rabies

Tetanus/polio/diphtheria

Tick borne encephalitis

Typhoid

Yellow fever

Other

Provide the names of any other vaccinations or tablets you have had *

Provide details about the vaccinations or tablets you have had *

For example, dates administered and type

Do you have any additional information to provide? *

Yes

No

Provide any additional information *

Terms and conditions *

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.

If you are human, leave this field blank.

Borough Fields
Royal Wootton Bassett
Swindon
SN4 7AX

Get directions

01793852302

About the surgery

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