Travel Questionnaire Name First Last Date of Birth Day Month Year PhoneAddress Street Address Address Line 2 City Postcode Which countries are you visiting? What is your date of departure? Day Month Year What is the duration of your stay? What type of areas are you visiting? Urban Rural Both Other Please specify What type of trip is it?Please select your trip typeBusinessSeeing familyHolidayReligiousBackpackingCharityOtherPlease specify Who are you travelling with?Please select your trip typeAloneWith friends/familyIn a GroupOtherPlease specify Are you currently taking any medications? (including contraception) Yes No Please give details of any medication(s) you are taking, including contraceptionDo you have any current health conditions? Yes No Please give details of your current health conditions:Are you currently taking a short course of medication, such as antibiotics? Yes No Please give details of any short courses of medication that you are currently taking:Do you have any allergies? Yes No Please provide details of any allergies you have:Have you ever had a reaction to a vaccine or malaria tablets in the past? Yes No Please tell us what vaccine or brand of malaria tablets you had a reaction to (if you remember) and what your reaction was:What previous travel vaccinations have you received? Please list any that you can remember having:Are you pregnant, planning pregnancy or breastfeeding? Pregnant Planning Pregnancy Breastfeeding None of the above Is there anything else you feel might be relevant? Optional