Travel Vaccination Questionnaire Please complete this form as accurately as you’re able. The information you provide will help us determine what vaccines you may require. Only submit a completed form once you have finalised your trip and confirmed dates. Travel Vaccination First Name * Last Name * Date of Birth * Phone * Address * Destination * Length of trip * Departure Date * Type of accommodation? * please select Hotel Friends/Family Home Camping Back packing/sleeping rough Other (please specify) Other accommodation? Do any of the following apply? Pregnant Taking regular medication Allergies Cancer treatment Taking steroids HIV positive Bad reaction to vaccinations Please detail any reactions to vaccines Please enter the date of any vaccinations you have had: Yellow Fever Typhoid Polio Tetanus Meningitis Hepatitis A Hepatitis B Cholera Immunoglobulin Please detail any other vaccinations you have had. I confirm this information is correct to the best of my knowledge * Confirm Today’s Date * If you are human, leave this field blank. Submit Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)