Travel Questionnaire Travel Questionnaire Travel Risk Assessment FormPlease 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 try to give us prior notice (preferably 6 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 Enter Email Confirm Email Destination(s)Please supply information about your trip in the sections belowUK Departure Date Day Month Year Total duration of trip (in days)Please enter a number from 0 to 99999.1st Country being visited Exact Location or Region City or RuralPlease selectCityRuralLength of stay (include stopover destinations) 2nd Country being visited Optional Exact Location or Region Optional City or Rural OptionalPlease selectCityRuralLength of Stay (include stopover destinations) Optional 3rd Country being visited Optional Exact Location or Region Optional City or Rural OptionalPlease selectCityRuralLength of Stay Optional Further InformationHave you taken out travel insurance for this trip? Do you plan to Travel abroad again in the future? Type of travel and purpose of trip – Please tick all that apply Business trip Holiday Expatriate Volunteer Work Healthcare Worker Staying in Hotel Cruise Ship Safari Pilgrimage Medical Tourism Backpacking Camping/ Hotels Adventure Diving Visiting Friends/ Family Please provide deatils of your personal medical historyAre you fit and well today? Yes No Do you have any allergies including food, Latex, Medication? Yes No If you answered yes to the above question please state allergies Optional Severe reaction to a vaccine before? Yes No Tendency to faint with Injections? Yes No Any Surgical Procedures in the past, including eg. your Spleen or Thymus Gland Removed Yes No If you answered yes to the above question please give details Optional Recent chemotherapy/ radiotherapy/ Organ transplant? Yes No Anaemia Yes No Bleeding/ Clotting disorders (Including History of DVT) Yes No Diabetes Yes No Disability Yes No Heart Disease (e.g.Angina, High Blood Pressure) Yes No Epilepsy/ Seizures Yes No Gastrointestinal (Stomach) Complaints Yes No Liver and or Kidney Problems Yes No HIV/ AIDS Yes No Immune System Condition Yes No Mental Health issues (including anxiety, depression) Yes No Mental Health issues (including anxiety, depression) Yes No Neurological (Nervous System) Illness Yes No Respiratory (lung) disease Yes No Rheumatology (joint) conditions Yes No Spleen Problems Yes No Any other Conditions? Optional Women OnlyAre you Preganant? Yes No Are you Breast feeding? Yes No Are you planning pregnancy while away? Yes No Are you currently taking any medication (including prescribed, purchased or a contreceptive pill?) Yes No If you answered yes to the above question please give details Optional Please supply information on any Vaccines or Malaria tablets taken in the pastTetanus/ Polio/ Diphtheria Optional Typhoid Optional Cholera Optional Rabies Optional Malaria Tablets Optional Yellow Fever Optional MMR Optional Hepatitis A Optional Hepatitis B Optional Japanese Encephalitis Optional BCG Optional Influenza Optional Pneumococcal Optional Meningitis Optional Tick Borne Encephalitis Optional Other Optional Any Additional Information (Please outline Below) Optional