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info@workplacewellness.health

info@workplacewellness.health

01225 809099

Management Referral
- Areas for Management Referral
- Ill Health Retirement assessments
Health Assessment
Confined Space Medicals

Contractors On Development Overseas (CONDO)

Executive Medicals

Fitness to Drive Medicals

Fit For Sporting Activities

Fit For Work/Study Abroad

Forklift Truck Medicals

Foster and Adoption Medicals

Ionising Radiation Medicals

Mine and Mine Rescue Medicals

Night and Shift Workers Medical

Non-Licensed Asbestos Medicals

Plant Operatives Medical

Pregnancy and Breastfeeding Risk Assessment

Recreational Diving Medicals

Safety Critical Medicals

Working At Heights Medicals

Working With Lead

Workstation Assessments
Health Surveillance
COSHH Assessments

Hand Arm Vibration Assessment

Hearing Test

Ionising Radiation Medicals

Non-Licensed Asbestos Medicals

Skin Surveillance and Dermatitis

Spirometry / Lung Function Tests
Other Services
About
Blog
Contact

Pre-Travel Questionnaire

Please complete this questionnaire if you wish to book an appointment with the Travel Clinic.
You must complete a separate form for all travellers.

Please ensure that you disclose your past medical history and current medical conditions to ensure that we can make a full risk assessment and evaluation of your needs.
(Note, if you are completing this form within 8 weeks of your departure date we will NOT be able to offer an appointment for your vaccinations)

Name(*)

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Date of Birth(*)

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Address(*)

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Postcode(*)

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Phone number(*)

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Email(*)

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Are you registered with Bradford on Avon Health Centre?(*)

Yes No

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Are you travelling in a family group?(*)

Yes No

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What is your departure date?(*)

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How long will you be away?(*)

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Which countries are you travelling to? Please include information on areas within each country as vaccination requirements may vary.(*)

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What is the purpose of your trip?(*)

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Where will you be staying?(*)

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What will be the location? (*)

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Type of trip(*)

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Will you be doing any specific adventurous activities?(*)

Yes No

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Please specify

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Do you have any allergies?(*)

Yes No

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Please specify

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Have you ever reacted to any vaccination?(*)

Yes No

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Please specify

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Do you feel faint when having a vaccination?(*)

Yes No

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Do you or any of your family suffer with epilepsy?(*)

Yes No

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Are you currently taking any medication?(*)

Yes No

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Please specify

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Have you suffered from any infections recently?(*)

Yes No

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Do you have any significant past medical history?(*)

Yes No

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Please specify

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Have you recently had any chemotherapy, radiotherapy, or immuno-suppressant treatment?(*)

Yes No

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Are you currently pregnant, planning to get pregnant or breast-feeding?(*)

Yes No

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Do you give consent to receive your vaccinations?(*)

Yes No

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Do you consent for medical staff to access your medical notes?(*)

Yes No

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Have you organised travel insurance? (*)

Yes No

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Please use this space to let us know any other information that you feel would be relevant or information (*)

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Workplace Wellness is the trading name of Bradford on Avon Occupational Health Services Ltd.
Registered in England: 9749251
VAT no. 27144823278
Registered Office: 29 Bridge Street Bradford on Avon Wiltshire BA15 1BY