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Your Guide to Coughs, Colds, Earache & Sore Throats for your Child
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#hellomynameis
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Dementia NI
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Aware
Feeling down or anxious? Beating the Blues 24/7 can help…
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Rethink Mental Illness
SANE
Order a Repeat Prescription
Wasted Medications
Antibiotic Use
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Antenatal screening
CRY-SIS Helpline
Newborn Hearing Test
Postnatal Depression
Scans, screening tests and check-ups
Stay Well – Flu jab for pregnant women
Sure Start Maternity Grant
Preventative Medicine
Annual Health Check
Flu Vaccination
Pneumococcal vaccine for adults
Screening Services
Shingles
Sexual Health & Sexuality
Contraceptive Advice
Free Condoms
Gender Dysphoria
LGBT Northern Ireland
Sexual Health Northern Ireland
Sexually transmitted disease
Young People
MACS – Supporting Children & Young People
Northern Ireland Youth Forum
The Mix
News
Menu
Home
About Us
Baby Friendly
Contact
Contact Telephone Numbers
Location
Opening Times
What to do when we are Closed
Health and Social Care Board
Making the Most of your Practice
Training/Teaching Practice
Our Team
Community Staff
Doctors
Nurses
Practice Administration Team
Practice Pharmacist
Practice Policies
Accessibility
Access to your Health Records
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Cookie Policy
Complaints
Confidentiality
Consent Protocol
Disability Access
Emergency Care Summary Record
Equality and Diversity
Freedom of Information
Infection Control Statement
Multi-Disciplinary Teams
Northern Ireland Health and Personal Services your rights
Non-Smoking Premises
Privacy Policy
Quality Assurance
Removal of Patients From our List
Shared Decision Making
Sharing your Information with Others
Subject Access Request (SAR) – Request your Records
Unacceptable Actions Policy
Website Terms and Conditions
Zero Tolerance
Regulations & Governance
Entitlement to NHS Treatment
Teenage Friendly
Administration
Get a Sick or Fit Note
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
Register with us as a New Patient
Temporary Services
Registration Policy
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
Appointments, Tests & Referrals
Appointments
See a Doctor or Healthcare Professional
Tests & Investigations
Referral for Further Care
Clinics & Services
Clinics
Additional Services provided
Antenatal Care
Child Health Checks
Travel Clinic & Holiday Vaccinations
Online Services
GP Online Services
Practice Services
Dementia Services
Interpreting Service
Home Visits
Housebound & Older People
Non NHS Services – Chargeable
Patient Transport Service
Pharmacy Collection Service
The Minor Ailments Scheme
Services for Carers
Your Health
Alcohol & Drug Services
Children’s Health
Action for Children in Northern Ireland
Childhood immunisation programme
Childline
Change4Life
Early Years
ERIC – The Children’s Bowl & Bladder Charity
Flu vaccine for children
Healthy Start – Vitamins in Northern Ireland
Measles, mumps and rubella (MMR)
Your Guide to Coughs, Colds, Earache & Sore Throats for your Child
General Health Advice
Antibiotic Awareness
When to use Antibiotics
Back problems
Diarrhoea and Vomiting – Dos and Don’ts
Hepatitis B
Healthier Choices
Managing your Infection
Strong painkillers and Driving
Walking – Physical Activity
Help & Support
A- Z of Services Belfast Health & Social Care Trust
Care & Support
Carer information
Carers Trust
Carers NI
Age NI
Alzheimer’s Society NI
Bereavement
Cruse Bereavement Care NI
British Heart Foundation NI
Health Unlocked
Patient/Asbestos Support Groups
PIPS – Public Initiative for Prevention of Suicide and Self Harm
MS Society
NICVA – Northern Ireland civic society
Samaritans
Orchid – Fighting Male Cancer
Organ Donation NI
Ovarian Cancer
Parkinson’s Disease
Penile Cancer
Same You
The Brain Tumour Charity
COVID-19 Information
Health & Wellbeing
Falls risk screening
Testicular lumps and swellings
Testicular Cancer – Check Yourself
Help & Support in your Area
New Life Counselling
Palliative Care information
End of Life Care
#hellomynameis
Cancer Support Services
Disability
Autism
Action on Hearing Loss
Disability Rights UK
Grant for people with disabilities
Hearing Loss
Learning Disabilities
Sense NI
Vision Impairment
Lifestyle Changes
Healthy Eating
Eatwell Guide
Food allergy
Food and Nutrition
Vitamin B12 or folate deficiency anaemia
Physical Activity – The Single best Medicine
Social Prescribing
Stop Smoking Service
Weight Management
Obesity
Long Term Conditions
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Breast Cancer (female)
Dementia
Dementia NI
Making Space
Diabetes
Drivers with diabetes on insulin or other medication
Diabetes network NI
Type 1 Diabetes
Type 2 Diabetes
Diabetic retinopathy
Epilepsy
High Blood Pressure (Hypertension)
Heart Disease
Osteoarthritis
Prostate Cancer
Stay Well – Winter advice
Transient Ischaemic attack (TIA)
Menopause
Mental Wellbeing
Anxiety
Aware
Feeling down or anxious? Beating the Blues 24/7 can help…
Five steps to mental wellbeing
Lifeline
Mental Health – General advice
Mind – For better Mental Health
Rethink Mental Illness
SANE
Order a Repeat Prescription
Wasted Medications
Antibiotic Use
Pregnancy & Baby
Antenatal screening
CRY-SIS Helpline
Newborn Hearing Test
Postnatal Depression
Scans, screening tests and check-ups
Stay Well – Flu jab for pregnant women
Sure Start Maternity Grant
Preventative Medicine
Annual Health Check
Flu Vaccination
Pneumococcal vaccine for adults
Screening Services
Shingles
Sexual Health & Sexuality
Contraceptive Advice
Free Condoms
Gender Dysphoria
LGBT Northern Ireland
Sexual Health Northern Ireland
Sexually transmitted disease
Young People
MACS – Supporting Children & Young People
Northern Ireland Youth Forum
The Mix
News
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Travel Risk Assessment Form
The Victoria Practice
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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.
*
I consent to the practice collecting and storing my data from this form.
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