Travel Questionnaire form

Fields marked with a red asterisk are compulsory. *

Please complete a form for each member of your travelling party (including children)

Your Details

First Name(s)

Surname

Date of birth

Email address

Itinerary

Date of departure

Return date

Country & areas to be visited

Type of trip

Type

Other (please state)

Accommodation

Type

Other (please state)

Further Medical Information

Have you had any antibiotic treatment in the last 8 weeks?

Have you suffered from depression or any other psychiatric illness?

Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness. Do you have epilepsy?

Do you have medical problems requiring regular medication or check ups?

Have you taken any steroids or had immunosuppressive therapy e.g. chemotherapy in the last 3 months?

Are you allergic to any medicines?

Have you ever reacted badly to any vaccine?

Are you pregnant or planning a pregnancy in the next 6 months?

Additional Information

Please provide any other information

Thank you for completing the form