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Kooth
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Menu
Home
Booking Appointments
Reception
About Us
Practice Newsletters
Our Team
Doctors
Nurses
Practice Administration Team
Practice Pharmacist
Allied Staff
COVID-19 Vaccinations
Aplos Primary Care Network
Contact
Contact Telephone Numbers
Ask Reception a Question
Friends & Family Test
Location
Parking at Sydenham Green
Opening Hours
Enhanced Hours
What to do when we are closed
Patient Opinion
Signing Up For Patient Forum
Subject Access Request (SAR)
Send a Message
Baby Friendly
Sydenham Garden
Greener Practice
Career Visits (work experience)
Friends and Family Test
Making the most of your Practice
Our Purpose
Teaching Involvement
Teenage Friendly
Regulations & Governance
Care Quality Commission (CQC)
Clinical Commissioning Group
GP Earnings
The NHS Constitution for England
Patients Forum
Patient Forum Frequently Asked Questions
Survey Report & Action Plan
Patients Forum Minutes of Meeting
Practice Policies
At the Practice
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our list
Safeguarding Children
Shared Decision Making
Social Media
Unacceptable Actions Policy
Zero Tolerance
Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Patient Record
Accessing your Record
Access for Others
Subject Access Requests (SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Organ Donation
Sharing your Information with Others
Summary Care Records (SCR)
How we use your Data
Confidentiality
Privacy Policy
Online Access
Proxy Access
Patient Rights
Complaints, Compliments & Suggestions
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website Policies
Accessibility
Cookie Policy
Copyright
Disclaimer
Clinics & Services
Appointments, Tests & Referrals
Appointments
Surgery Times
Book an Appointment
Cancel an Appointment
GP Extended Access Service
Hospital Appointments – Book, Cancel or Change
Get Immediate Help for Minor Injuries
Help with your GP Appointment
NHS 111 online – Get help for your Symptoms
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Access your Test Results
Blood Tests
Other Common Tests
Urine Tests
X-Rays & Scans
Remote Monitoring
Clinics
Antenatal Care
Child Health Checks
Clinics we provide
Long Term Conditions
NHS Health Check aged 40 – 74
Online Services
Connect Care
Order a Repeat Prescription
Antibiotic Use
Electronic Prescriptions
Wasted Medications
NHS App
Practice Services
Register with us as a New Patient
Elderly Patients
Counselling
Get a Sick or Fit Note
Advocacy Service
Dementia Services
Cervical Screening
Diabetes Services
Hepatitis B Immunisation
Housebound & Older People
Home Visits
Interpreting Service
NHS Services
New Medicine Service (NMS)
Non NHS Services – Chargeable
Chargeable Services and Fees
Patient Transport Service
Texting Service
Your Record
Access your records via Patient Access
Health Review Forms
Alcohol Consumption Review Form
Asthma Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
Update your Personal Details Forms
Change of Contact Details Form
Register as a Carer Form
Register for Online Services Form
Summary Care Record Opt-out Form
Communication Consent Form
Type 1 Opt-outs
Travel Vaccinations
Advice & Info
COVID-19 Information
Help & Support Organisations
Who Do I See?
Your Health
Alcohol & Drug Services
Children’s Health
Change4Life
Children and Young People’s Services
Childline
ERIC – The Children’s Bowl & Bladder Charity
Triple P – Positive Parenting Programme
Your Guide to Childrens Coughs, Colds, Earache & Sore Throats
Help & Support
Care & Support
Carer information
Support for carers in Lewisham
Are you a Carer?
Carers UK
Services for Carers
Age UK
Bereavement
At a Loss
Family Lives
Health Unlocked
MS Society
Orchid – Fighting Male Cancer
Penile Cancer
Same You
Shelter – England
The Motor Neurone Disease Association (MNDA)
The Pavement
The Brain Tumour Charity
Health & Wellbeing
More about Sprains and Strains
Food Allergy
Vitamin B12 or folate deficiency anaemia
Testicular Cancer – Check Yourself
Help & Support in your Area
Housing Applications
Lewisham Council
Mindkit
Palliative Care information
End of Life Care
#hellomynameis
What end of life care involves
End of life care
Together for short Lives
Cancer Support Services
Together for Short Lives
Disability
Autism
Action on Hearing Loss
British Deaf Association
Contact – for Families with Disabled Children
Disability Rights UK
Deaf or Hard of Hearing
Get Active with a Disability
How to Care for a Disabled Child
Learning Disability
National Autistic Society
SCOPE – Equality for Disabled People
Vision Impairment
General Health Advice
Antibiotic Awareness
Diarrhoea and Vomiting – Do’s and Don’ts
Healthcare Associated Infection
Managing an Infection
Menopause
My Live Well with Pain
Lifestyle Changes
Healthy Eating
Physical Activity – The Single best Medicine
Social Prescribing
Weight Management
Stop Smoking Service
Long Term Conditions
Asthma
Breast Cancer (female)
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Heart Disease
Dementia
Dementia with Lewy bodies
Diabetes
Epilepsy
High Blood Pressure (Hypertension)
Osteoarthritis
Prostate Cancer
Mental Wellbeing
Depression
Doc Ready
Dealing with a Mental Health Crisis or Emergency
Every Mind Matters
Feeling down or anxious? Beating the Blues 24/7 can help…
Healthtalk
Lifelink
Making Space
Mind – for better Mental Health
Mental Health Helplines
Mental Health – General Advice
Mental Health & Money Advice
Mental Health Issues if you’re Gay, Lesbian or Bisexual
Rethink Mental Illness
Samaritans
SANE
Time to Change
Pregnancy & Baby
Am I Pregnant?
CRY-SIS Helpline
Maternity Services Locations
Postnatal Care
Postnatal Depression
Smoking affects your Unborn Baby
Start 4 Life
Sexual Health & Sexuality
Contraceptive Advice & Sexual Health
Your Contraception Guide
Free Condoms
Gender Dysphoria
LGBT Foundation
Maria Stopes UK
Sexual and reproductive health in Lewisham
Sexually Transmitted Disease
Preventative Medicine
Annual Health Check
Flu Vaccination
HPV Vaccination
Pneumococcal vaccine
Screening Services
Shingles
Young People
Can I see the GP or Nurse on my own?
Chlamydia
Kooth
The Mix
Youth First
Young Minds
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Travel Risk Assessment Form
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Travel Risk Assessment Form
Travel Risk Assessment
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Gender
*
Male
Female
Date of Departure
*
Please use format day/month/year e.g. 12/05/2019
Date of Return
*
Please use format day/month/year e.g. 12/05/2019
Please give details of country to be visited, length of stay, and how remote you’ll be from medical help
*
Type of trip
*
Business
Pleasure
Other
Holiday type
*
Package
Self organised
Backpacking
Camping
Cruise ship
Trekking
Accommodation
*
Hotel
Relatives / family home
Other
Travelling
*
Alone
With family / friend
In a group
Staying in area which is
*
Urban
Rural
Altitude
Planned activities
*
Safari
Adventure
Other
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
*
List any current or repeat medications
*
Do you have any allergies for example to eggs, antibiotics, nuts?
*
Have you ever had a serious reaction to a vaccine given to you before?
*
Yes
No
Don’t Know
Does having an injection make you feel faint?
*
Yes
No
Don’t Know
Do you or any close family members have epilepsy?
*
Yes
No
Don’t Know
Do you have any history or mental illness including depression or anxiety?
*
Yes
No
Don’t Know
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
*
Yes
No
Don’t Know
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
*
Yes
No
Don’t Know
Please type below any further information which may be relevant:
Have you ever had any of the following vaccinations / malaria tablets?
*
Tetanus
Polio
Diptheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Other / Malaria tablets
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
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