The Upstairs Surgery

Pre-Travel Assessment Form

Please ensure this form is completed atleast 3 working days prior to your travel vaccine appointment

Pre-Travel Assessment Form
Type of travel and purpose of trip - PLEASE TICK ALL THAT APPLY
Are You Well Today
Have You Ever Had A Reaction To Any Injections
Have You Had Any Surgery In The Past, Including e.g. Your Spleen or Thymus Gland Removed
Recent Chemotherapy/Radiotherapy/Organ Transplant
Do You Have Anaemia?
Bleeding/Clotting Disorders (INCLUDING DVT)
Do You Have History Of Heart Disease?
Are You Diabetic?
Do You Suffer From Epilepsy/Seizures
Liver/Kidney Problems
HIV/AIDS?
Mental Health Issues?
WOMEN ONLY - PLEASE TICK ALL THAT APPLY
Have You Had Any Of The Followin Vaccines In The Past?

Privacy Protection

Information entered into survey forms is used only for the purposes of processing your survey information and is stored and accessed securely by designated staff.

Issues raised in comments may be discussed between relevant members of staff. The information is used for quality monitoring purposes, in line with the expectations of those submitting the feedback.

Any personal information transmitted via survey forms may be anonymised when this is required to ensure compliance with General Data Protection Regulation.

This information is not shared with any external third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Cancer Support
Your Service
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Hearing Aids
& Services