Portcullis Travel Risk Assessment Form

Please complete this form in the spaces below online and submit it via our website in order to book your appointment with the nurse prior to your travel appointment.

Alternatively you can print of the sheet below, fill it in and hand it in at reception

Travel Risk Assessment Form

You will need to book a 20minute appt with the nurse for the travel clinic.

Travel Risk Assessment Form

To register with our practice, ALL YOU NEED TO DO IS FILL IN THE FORM BELOW AND SUBMIT IT. Or you can print the forms and hand them in to reception or send them by post

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*

Day
Month
Year
NHS Number (if you know it)
Contact Telephone numbers.(please include mobile phone if you have one)*

Please add all relevant tel nos
If you have an Email please add below
Vaccination Status for Covid Vaccine*
- I have had my 1st dose Pfizer vaccine only
- I have had my 1st dose Astra Zeneca vaccine only
- I have had my 1st dose Moderna vaccine only
- I have had my 1st and 2nd dose Pfizer vaccine
- I have had my 1st and 2nd dose Astra-Zeneca vaccine
- I have had my 1st and 2nd dose Moderna vaccine
- I am not vaccinated for Covid
Date of Outbound Trip (Date of your Flight, coach or boat trip leaving the UK)*

Day
Month
Year
The practice is not able at this moment to provide Private PCR tests at the moment as we do not have capacity, if we were able to source them would you be interested in having PCR tests provided by the practice in future?
- Yes
- No
- Unsure
Date of Return Trip (Date of your Flight, coach or boat trip leaving the UK)*

Day
Month
Year
Ethnicity
Please include information about your ethnicity (optional)
Please give a description of each country you are visiting on your trip and how many days you will be staying in each country*
Describe the type of trip*
- Business
- Holiday self organised beach holiday
- Holiday self organised city holiday
- Holiday self organised campling or hostel stays
- Holiday self organised backpacking
- Holiday includes trip to jungle area or safari
- Holiday includes travel in rural areas
- Holiday includes travel at high altitude
- Holiday package beach holiday
- Holiday package city holiday
- Holiday package cruise ship
- Holiday package on a bus trip
Please tick all the boxes that apply to your trip
Has you been diagnosed with any of the following medical conditions?*
- No medical conditions
- Diabetes on insulin
- Diabeties on oral medication or diet only
- Asthma
- COPD (Chronic Lung condition)
- Stroke
- Heart Condition
- Dementia
- Mental Health Condition
- Epilepsy
- Parkinsons
- Rheumatoid Arthritis
- Osteoarthritis
- High Blood pressure
- Cancer (on active treatment)
- Thyroid problems
- Other
Please tick all those that apply to you
Please list any allergies*
Have you ever had a serious reaction to a vaccine before particularly an anaphylactic type reaction?*
Please describe what happened
Please list any medications you are on. If possible include the dose you are on.*
If you are not on any medication write none.
Vaccination History*
- Tetanus
- Typhoid
- Meningitis
- Rabies
- polio
- Hepatitis A
- Hepatitis B
- Yellow Fever
- Diptheria
- Japanese Encephalitis
- Tuberculosis
- Influenzae
- Cholera
- Malarial tablets
- Unsure
Have you ever had any of the following vaccines? Please tick all relevant boxes. Please write down the approximate date you last had this vaccine.
Have you ever been diagnosed with a clot in your leg (deep vein thrombosis) or a clot in your lung (pulmonary embolism) ?
Please describe how you got the clot and if it was related to travel
For women only is there any possibiilty you could be pregnant? Are you pregnant or currently breast-feeding?
Please write down your passport number*
Upload a copy of a photo ID (please send if possible)
Max. file size: 2 MB.
Passport or Driver's licence please. Ideally upload a photo straight away with this application or send it to us by email to portcullis.dutymanager@nhs.net. If you don't have either of these IDs, please fill in the form and call us. If you are registering a child a copy of their birth certificate or a parents ID may be acceptable.
Has anyone in your family been diagnosed with any of the following medical conditions?
- No medical conditions in my family
- Diabetes on insulin
- Diabeties on oral medication or diet only
- Asthma
- COPD (Chronic Lung condition)
- Stroke
- Heart Condition
- Dementia
- Mental Health Condition
- Epilepsy
- Parkinsons
- Rheumatoid Arthritis
- Osteoarthritis
- High Blood pressure
- Cancer (on active treatment)
- Thyroid problems
- Other
For close family members (parents, siblings, grandparents, children) Please tick all those that apply to your family
Phone
This field is for validation purposes and should be left unchanged.

NEW PATIENTS: How do I register?

How can I book an appointment?

How can I re-order a prescription?

Information about Services

How to Register for Online Access

Email for Advice, Help or an Appointment

How can I update my details?

How can I give feedback to improve services?

Accessible Information Standard

Advice about Covid-19

Book an Appointment with a Counsellor

Information about the Covid-19 Vaccines

Opening Times

Monday
08:30 until 20:00
6-8pm Pre-booked appointments only.Call 111 for advice OOH
Tuesday
08:30 until 20:00
6-8pm Pre-booked appointments only.Call 111 for advice OOH
Wednesday
08:30 until 20:00
6-8pm Pre-booked appointments only.Call 111 for advice OOH
Thursday
08:30 until 18:30
Call 111 for advice OOH
Friday
08:30 until 20:30
Open 1-2 Fridays a month. 6-8pm Pre-booked appointments only.Call 111 for advice OOH
Saturday
08:30 until 12:30
Open 1-2 Sat per month Pre-booked appointments only. Call 111 for advice OOH
Sunday
CLOSED
Call 111 for advice OOH

Useful Links

Portcullis Surgery

Portcullis Travel Risk Assessment Form

Travel Risk Assessment Form

Opening Times

Useful Links

How can I update my details?

How can I give feedback to improve services?