Travel Assessment Form Travel Questionnaire Please complete the form below to receive information about the travel immunisations you may need. Most vaccines should be administered at least two weeks before travel, and some more complex vaccination schedules may require more time. To ensure we can accommodate your needs, please provide at least six weeks’ notice before your intended travel date.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)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 OptionalFurther 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 OptionalOther Information you should disclose OptionalPhone OptionalThis field is for validation purposes and should be left unchanged.
