Pembroke Medical Group

Pembroke House Surgery, 266-268 Torquay Road, Paignton, Devon, TQ3 2EZ

Telephone: 01803 553558

Sorry, we're closed

Parkhill Surgery, Parkhill Road, Torquay TQ1 2AR | Telephone: 01803 212489

Travel Risk Assessment Form

Travel Risk Assessment Form

Name(Required)
Date of birth(Required)
Gender
Date of departure
About your trip
Country to be visited
Exact location or region
City or Rural
Length of stay
 
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip - please tick all that apply.
Are you fit and well today?

Any allergies including food, latex, medication?

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

Tendency to faint with injections?

Any surgical operations in the past, including e.g. open heart surgery, spleen or thymus gland removal?

Recent chemotherapy/radiotherapy/organ transplant

Anaemia?

Bleeding/clotting disorders (including history of DVT)

Heart disease (e.g. angina, high blood pressure)

Diabetes?

Additional needs and/or disability?

Epilepsy/seizures (or in a first degree relative)?

Gastrointestinal (stomach) complaints?

Liver or Kidney problems?

HIV/AIDS?

Immune system condition e.g. blood cancer?

Mental health issues (including anxiety, depression)?

Neurological (nervous system) illness?

Respiratory (lung) disease?

Rheumatology (joint) conditions?

Spleen problems?

Are you or your partner pregnant or planning a pregnancy?
Are you breast feeding (if applicable)?
Have you or anyone in your family undergone FGM / been cut / circumcised?
Please supply information on any vaccines or Malaria tablets taken in the past
This field is for validation purposes and should be left unchanged.

Pembroke House

  • Monday
    08:00am to 06:00pm
  • Tuesday
    08:00am to 06:00pm
  • Wednesday
    08:00am to 06:00pm
  • Thursday
    08:00am to 06:00pm
  • Friday
    08:00am to 06:00pm
  • Saturday
    CLOSED
  • Sunday
    CLOSED

Parkhill Surgery

  • Monday
    08:00am to 06:00pm
  • Tuesday
    08:00am to 06:00pm
  • Wednesday
    08:00am to 06:00pm
  • Thursday
    08:00am to 06:00pm
  • Friday
    08:00am to 06:00pm
  • Saturday
    CLOSED
  • Sunday
    CLOSED
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