Travel Assessment Form 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 try to give us prior notice (preferably 6 weeks).TitleMrMrsMissMsMxDrOtherFull 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 Destination(s)TRIP DETAILSUK 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 InformationTRIP DESCRIPTIONPurpose of your trip OptionalSelect an optionBusinessPleasureOtherType of Trip OptionalSelect an optionPackageSelf organisedBackpackingCampingTrekkingCruise ShipOtherAccommodation OptionalSelect an optionAloneWith friends &/or FamilyGroupOtherTravelling OptionalSelect an optionAloneWith Family/FriendsIn a GroupLocation Setting OptionalSelect an optionUrbanRuralAltitudeOtherPlanned Activities OptionalSelect an optionSafariAdventureOtherPERSONAL MEDICAL HISTORYAre 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 OptionalVACCINATION HISTORYHave you ever had any of the following vaccinations / tablets and if so, when? OptionalSelect all that apply to youTetanusPolioDiphtheriaTyphoidHepatitis AHepatitis BMeningitisYellow FeverInfluenzaRabiesJapanese B EncephTick BorneMalariaConsent I consent to the practice collecting and storing my data from this form. OptionalTHIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA