Please note that we will not respond to any medical information or questions received via this form.

The information you supply us will be used lawfully, in accordance with the Data Protection legislation and GDPR.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of communicating with the practice.

Are my details secure?

The internet is not a secure place, however, we have gone to great lengths to make sure the information you submit to us is as secure as possible.

We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our server. When you submit your information, it is safely transmitted over the web in an encrypted form and deciphered using the private key at its intended location.

Other Notes:

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Integrated Care Partnership

Alexandra Road
Epsom
Surrey
KT17 4BL
Telephone: 01372 724434

Travel Risk Assessment

ICP – Travel Risk Assessment Form 2019
Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
Sex

Please supply information about your trip

Type of travel and purpose of trip
Please tick all that appy

Please supply details of your personal medical history

Are you fit and well today?
Any allergies including food, latex, medication?
Severe reaction to a vaccine before?
Tendency to faint with injections?
Any surgical operations in the past?
Recent chemotherapy/radiotherapy/organ transplant?
Anaemia?
Bleeding /clotting disorders (including history of DVT)?
Heart disease (e.g. angina, high blood pressure)?
Diabetes?
Disability?
Epilepsy/seizures?
Gastrointestinal (stomach) complaints?
Liver and or kidney problems?
HIV/AIDS?
Immune system condition?
Mental health issues (including anxiety, depression)?
Neurological (nervous system) illness?
Respiratory (lung) disease?
Rheumatology (joint) conditions?
Spleen problems?
Any other conditions?
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised?
Are you currently taking any medication (prescribed, purchased, a contraceptive pill or vitamins)?

Please supply information on any vaccines or malaria tablets taken in the past

Additional information

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 your Practice’s Privacy Policy to discover how we protect and manage your submitted data.
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