Travel Vaccination Pre-Travel Questionnaire Name First Last Date of Birth Day Month Year Contact NumberGender Female Male Email Enter Email Confirm Email Date of Departure Day Month Year Duration of TripCountry/Countries to be VisitedType of Travel / Purpose of Trip Holiday Backpacking Cruise Ship Pilgrimage Safari Business Camping/Hostel Volunteering Visiting friends/family Healthcare Worker Other Please specifyAny additional information OptionalWho are you travelling with? With Family/Friends Alone In a group Are you currently taking any medications, including contraception? Yes No Please provide details.Do you have any current health conditions? Yes No Please provide details.Are you currently taking a short course of medication such as antibiotics? Yes No Please provide details.Do you have any allergies? Yes No Please provide details.Have you ever had a reaction to a vaccine or malaria tablet in the past? Yes No Please tell us which vaccine or brand of malaria tablets (if you remember)Previous travel vaccinations you have received.Please list any that you remember having.Are you pregnant Yes No N/A How many weeks?Are you planning a pregnancy? Yes No N/A Are you breastfeeding? Yes No N/A Anything else you feel might be relevant. OptionalPlease note as stipulated on our website, this form has to be completed 8 weeks prior to the date of travel otherwise we cannot carry out the assessment. Please allow 14 days after completing this questionnaire before contacting the surgery if we have not contacted your first. For further travel advice you can look up; fitfortravel.nhs.uk/destinations travelhealthpro.org.uk/countries