Travel Questionnaire Please complete the form below to get more information about what travel immunisations you require. Most vaccines can be given at least 2 weeks before travel, and some more complicated regimes take longer. Please try to give us prior notice (6-12 weeks).Title Mr Mrs Miss Ms Mx Dr Other Full NameDate of Birth Day Month Year Address Street Address Address Line 2 City Postcode Contact NumberEmail Destination(s)UK Departure Date Day Month Year UK Return Date Day Month Year Total duration of trip (in days)Are you visiting more than 1 location?1st destination being visitedArea/City of 1st destinationLength of stay2nd destination being visited OptionalArea/City of 2nd Destination OptionalLength of stay (destination 2) Optional3rd destination being visited OptionalArea/City of 3rd Destination OptionalLength of stay (destination 3) OptionalAbout Your TripPurpose of your trip: Business Pleasure Other Holiday type: Package Self organised Backpacking Camping Trekking Cruise Ship Other Travelling with: Alone With friends &/or Family Group Purpose of your trip (Other)Holiday type (Other)Accommodation Hotel Hostel Camping Staying with relatives/friends Other Setting: Urban/City Rural/Village High Altitude/Mountains Desert Other Planned Activities: Safari Adventure Tourism Volunteering Backpacking Accommodation (Other)Setting (Other)Medical InformationAre you fit for travel? Yes Optional No Optional Women Only: Is there any possibility you may be pregnant? Yes Optional No Optional Do you have any allergies? Yes Optional No Optional Please state allergiesOther Information you should disclose Optional
