Travel Vaccinations

PLEASE READ PRIOR TO COMPLETION

The surgery is unable to provide any advice regarding COVID travel restrictions.
Before completing the travel questionnaire, please visit https://travelhealthpro.org.uk/ to check the vaccination requirements for your destination(s).
Travel advice and immunisations are offered, however please ensure that you book the appointment at least 6 weeks before you travel.
Please note that there is a charge for some of these vaccinations.
It is the travellers responsibility to check the entry requirements for their destination. Information can be found via the following link: https://www.gov.uk/foreign-travel-advice
Each individual traveller (including children) needs to complete a separate travel questionnaire form. We are unable to accept forms with multiple patient details.

Surname(Required)

First Name(Required)

NHS Number (if known)

Date of Birth(Required)

Address & Postcode(Required)

Contact Telephone Number(Required)

Date

Please select the practice location most relevant to this Online Form submission

Patient details

Title*

First Names*

Surname*

Date of Birth*

Gender*

NHS Number

Birth Town*

Birth Country*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

Patient Health Questionnaire

Ethnicity*

Main language spoken:*

Are you cared for?

Yes

If yes, who is your carer?

Carer Name

Relationship to you

Carer contact number

Are you a carer?

Yes

If yes, who do you care for?

Relationship to you

Contact number

Health Information

Smoking status*

If you are a current smoker, how many do you smoke per day?

Have you been offered any stop smoking advice in the past year?

Height (cms/ft & ins)*

Weight (kg/stones & lbs)*

Waist measurement (approx cms/ins)

Exercise

Units:

Pint of regular beer/cider/lager - 2 units
Alcopop or can of beer/lager/cider - 1.5 units
Glass of wine (175ml) - 2 units
Single measure of spirts - 1 unit
Bottle of wine - 9 units

If your score (table 1 and 2 combined) is 5 points or more, please complete the Extended Alcohol questionnaire below.

Alcohol - Table 1

	1-2 drinks (0 points)	3-4 drinks (1 point)	5-6 drinks (2 points)	7-8 drinks (3 points)	9+ drinks (4 points)
How many standard alcohol drinks do you have on a typical day when you are drinking?

Alcohol - Table 2

	Never (0 points)	Less than Monthly (1 point)	Monthly (2 points)	Weekly (3 points)	Daily (or almost daily) (4 points)
How often do you have a drink that contains alcohol?
How often do you have 6 or more standard drinks on one occasion?

Extended Alcohol Questionnaire

Units:

Pint of regular beer/cider/lager - 2 units
Alcopop or can of beer/lager/cider - 1.5 units
Glass of wine (175ml) - 2 units
Single measure of spirts - 1 unit
Bottle of wine - 9 units

If your score above is 5 points or more, please complete the Extended Alcohol questionnaire below (tables 3 and 4).

Alcohol - Table 3

	1-2 drinks (0 points)	3-4 drinks (1 point)	5-6 drinks (2 points)	7-8 drinks (3 points)	9+ drinks (4 points)
How many standard alcohol drinks do you have on a typical day when you are drinking?

Alcohol - Table 4

	Never (0 points)	Less than Monthly (1 point)	Monthly (2 points)	Weekly (3 points)	Daily (4 points)
How often do you have a drink that contains alcohol?
How often do you have 6 or more standard drinks on one occasion?
How often in the last year have you found you were not able to stop drinking once you started?
How often in the last year have you failed to do what was expected of you because of drinking?
How often in the last year have you needed an alcoholic drink in the morning to get you going?
How often in the last year have you had a feeling of guilt or regret after drinking?
How often in the past year have you not been able to remember what happened when drinking the night before?
Have you or someone else been injured as a result of your drinking?
Has a friend/relative/Dr/health worker been concerned about your drinking or advised you to cut down?

Immunisations

Diptheria

Tetanus

Polio

Typhoid

Hepatitis A

Hepatitis B

HIB

BCG

Men C

MMR

Flu

Pneumonia

Additional questions for female patients

Date of last cervical smear

Date of last mammogram

Date of last hysterectomy

Breast disease (date/details)

Contraception

HRT

Information for new patients: about your Summary Care Record

To help the staff involved in your care make better and safer decisions about how best to treat you.

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Your options are outlined below; please indicate your choice on the form below.

a) Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only.

b) Express consent for medication, allergies, adverse reactions and additional information.
You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.

c) Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

Please note that it is not compulsory for you to complete this consent form. If you choose not to complete this form, a Summary Care Record containing information about your medication, allergies and adverse reactions and additional further medical information will be created for you as described in point b) above.

The sharing of this additional information during the pandemic period will assist healthcare professionals involved in your direct care and has been directed via the Control of Patient Information (COPI) Covid-19 – Notice under Regulation 3(4) of the Health Service Control of Patient Information Regulations 2002.

You are free to change your decision at any time by informing your GP practice.

Having read the above information regarding your choices, please choose one of the options below.

Yes - I would like a Summary Care Record

a. Express consent for medication, allergies and adverse reactions only

b. Express consent for medication, allergies, adverse reactions and additional information

No - I would not like a Summary Care Record

c. Express dissent for Summary Care Record (opt out)

Patient first name*

Patient Surname*

Date of Birth*

NHS Number (if known)

Address

Postcode

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

Date

If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide your details (name) below:

Relationship to Patient

Parent

Legal Guardian

Lasting Power of Attorney

Identity Documentation

Please upload two forms of proof of identity. One photographic identity document and proof of address. Photographic identity documents are not required for child registrations.

Photographic ID - over 18

Drop files here or

Max. file size: 128 MB.

Driving licence, passport or Identity Card

Proof of address

Drop files here or

Max. file size: 128 MB.

Utility bill, council tax or bank statement

Online Access

I wish to be enrolled for Online Access (NHS App, SystmOne Online)*

Yes

I already have online access enabled

By ticking YES, you are consenting to be registered for Online Access to your medical record. You will receive by email or SMS your log in details.

This field is for validation purposes and should be left unchanged.

PLEASE READ PRIOR TO COMPLETION

The surgery is unable to provide any advice regarding COVID travel restrictions.
Before completing the travel questionnaire, please visit https://travelhealthpro.org.uk/ to check the vaccination requirements for your destination(s).
Travel advice and immunisations are offered, however please ensure that you book the appointment at least 6 weeks before you travel.
Please note that there is a charge for some of these vaccinations.
It is the travellers responsibility to check the entry requirements for their destination. Information can be found via the following link: https://www.gov.uk/foreign-travel-advice
Each individual traveller (including children) needs to complete a separate travel questionnaire form. We are unable to accept forms with multiple patient details.

Surname(Required)

First Name(Required)

NHS Number (if known)

Date of Birth(Required)

Address & Postcode(Required)

Contact Telephone Number(Required)

Church Street Surgery

Travel Vaccinations