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 Name Date 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 visited Area/City of 1st destination Length of stay2nd destination being visited Optional Area/City of 2nd Destination Optional Length of stay (destination 2) Optional3rd destination being visited Optional Area/City of 3rd Destination Optional Length 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 allergies Other Information you should disclose Optional
