Travel Questionnaire Travel Questionnaire Please complete the form below to get more information about what travel immunisations you require. Please allow us 6 weeks to process your request and ensure your vaccinations are given in a timely manner. Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Title Mr Mrs Miss Ms Mx Dr Other Full NameDate of Birth Day Month Year Address Street Address Address Line 2 City Postcode Contavt NumberEmail Enter Email Confirm Email Women Only: Is there any possibility you may be pregnant? Yes No Destination(s)UK Departure Date Day Month Year Total duration of trip (in days)Please enter a number from 0 to 99999.Country being visited – Please specify the areaLength of stay (include stopover destinations)2nd Country being visited (specify areas if long haul) OptionalLength of Stay3rd Country being visited (specify areas if long haul) OptionalLength of StayFurther InformationPurpose of your trip Business Pleasure Other Holiday type Package Self organised Backpacking Camping Trekking Cruise Ship Other Accommodation Alone With friends &/or Family Group Other Setting Urban Rural Altitude Other Planned Activities Safari Adventure Other Are you fit for travel? Yes No Do you have any allergies? Yes No Please state allergies OptionalOther Information you should disclose Optional