Travel Risk 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. (FORMS MUST BE COMPLETED 6-8 WEEKS BEFORE TRAVEL, FAILING TO DO SO MAY MEAN YOU HAVE TO SOURCE THESE PRIVATELY) ANY FORMS SUBMITTED WITH 2 WEEKS OR LESS LEFT TO TRAVEL DATE WILL NOT BE DEALT WITH AND YOU WILL NEED TO SEEK A LOCAL PHARMACY FOR ADVICETitle 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 No Destination(s)UK Departure Date Day Month Year Total duration of trip (in days)Please enter a number from 0 to 99999.1st Country and region being visited (specify areas if long haul)Length of stay (include stopover destinations)2nd Country and region being visited (specify areas if long haul) OptionalLength of Stay Optional3rd Country and region being visited (specify areas if long haul) OptionalLength of Stay OptionalFurther InformationPurpose of your trip Business Pleasure Other Holiday type Package Self organised Backpacking Camping Trekking Cruise Ship Other Accommodation With friends &/or Family Hotel/AirBnB 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