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 (8-10 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 Enter Email Confirm Email Section BreakWomen Only: Is there any possibility you may be pregnant? Yes Optional No Optional Section BreakDestination(s)UK Departure Date Day Month Year Total duration of trip (in days)Please enter a number from 0 to 99999.1st Country being visited (specify areas if long haul)Length of stay (include stopover destinations) Optional2nd Country being visited (specify areas if long haul) OptionalLength of Stay Optional3rd Country being visited (specify areas if long haul) OptionalLength of Stay OptionalSection BreakFurther InformationPurpose of your trip Business Optional Pleasure Optional Other Optional Holiday type Package Optional Self organised Optional Backpacking Optional Camping Optional Trekking Optional Cruise Ship Optional Other Optional Accommodation Alone Optional With friends &/or Family Optional Group Optional Other Optional Setting Urban Optional Rural Optional Altitude Optional Other Optional Planned Activities Safari Optional Adventure Optional Other Optional Are you fit for travel? Yes Optional No Optional Do you have any allergies? Yes Optional No Optional Please state allergies OptionalSection BreakOther Information you should disclose Optional
