Travel Form Please complete the form below to get more information about what travel immunisations you require. Please call reception 1 week after you have submitted the form. Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Please try to give us prior notice (preferably 6 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 Women Only: Is there any possibility you may be pregnant? Yes Optional No Optional Destination(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)Please add any stop over countries, even if its for one nightLength 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 OptionalFurther InformationPurpose of your trip Business Holiday Expatriate Volunteer Work Healthcare Worker Medical Tourism Visiting friends/Family Holiday type Package Backpacking Camping Trekking Cruise Ship Pilgrimage Safari Adventure Diving Accommodation Hotel Camping Hostels Cruise Setting Urban Rural Altitude Other If other, Please specify OptionalPlanned Activities Safari Adventure Diving None Other If other, please specify OptionalAre you fit and well today Yes No If no, Please specify your symptoms OptionalDo you have any allergies? Yes No Please state allergies OptionalHave you or anyone in your family, had a severe reaction to a vaccine or malaria medication before Yes No Do you have a tendency to faint with injections Yes No Have you had any surgical operations in the past Yes No If yes, please specify OptionalHave you had any of the following recently Chemotherapy Optional Radiotherapy Optional Organ Transplant Optional Have you got Anaemia Yes No Have you got a bleeding/clotting disorder Yes No Have you got heart disease (e.g angina, high blood pressure Yes No If yes, please specify OptionalHave you got diabetes Yes No Have you any additional needs/or a disability Yes No If yes, please specify OptionalDo you suffer from epilepsy or seizures Yes No Do you have gastrointestinal (stomach) complaints Yes No Do you have any liver and/or kidney problems Yes No Do you have HIV/AIDS Yes No Do you have an immune system condition Yes No If yes, please specify OptionalDo you have any mental health issues Yes No If yes, please specify OptionalDo you have any Neurological (nervous system) illnesses Yes No If yes, please specify OptionalDo you have any respiratory (lung) diseases Yes No If yes, please specify OptionalDo you have any spleen problems Yes No If yes, please specify OptionalDo you have any rheumatology (joint) conditions Yes No If yes, please specify OptionalDo you have any other conditions Yes No If yes, please specify OptionalPlease list any medication you are currently taking (Including prescribed, purchased or contraceptive pill) Optional