Travel Questionnaire Please complete the form below to get more information about what travel immunisations you require. Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Please give us at least 6 weeks’ notice of your travel. The surgery will contact you prior to your trip. Please note, if you are not travelling for some time, we may not contact you until approximately a month before your travel date. If you are making a travel vaccination query please complete a separate form for each individual member of the family that is travelling with you. Full Name Date of Birth Day Month Year Address Street Address Address Line 2 City Postcode Contact NumberEmail Enter Email Confirm Email Women Only: Is there any possibility you may be pregnant? Yes Optional No Optional 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) Optional 2nd Country being visited (specify areas if long haul) Optional Length of Stay Optional 3rd Country being visited (specify areas if long haul) Optional Length of Stay Optional Further InformationPurpose of your trip Business Optional Holiday Optional Other Optional Holiday type Package Optional Self organised Optional Backpacking Optional Camping Optional Trekking Optional Cruise Ship Optional Other Optional Accommodation Hotel Optional Friends 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 Optional Other Information you should disclose Optional