Online Travel Form To be completed by traveller prior to appointment. Step 1 of 2 50% Name First Last Your country of origin Date of Birth Day Month Year Gender Male Female Non-binary Address Street Address Address Line 2 City Postcode Contact NumberEmail Enter Email Confirm Email Information about your tripDate of departure Day Month Year Total duration of trip Destination(s)1. Country to be visited Exact location or region City or Rural? City Rural Length of stay 2. Country to be visited Optional Exact location or region Optional City or Rural? City Optional Rural Optional Length of stay Optional 3. Country to be visited Optional Exact location or region Optional City or Rural? City Optional Rural Optional Length of stay Optional What modes of transport will you be using? Have you taken out travel insurance for this trip? Yes No Do you plan to travel abroad again in the future? Yes No Type of travel and purpose of trip Holiday Staying in hotel Backpacking Business trip Cruise ship trip Camping/hostels Expatriate Safari Adventure Volunteer work Pilgrimage Diving Healthcare worker Medical tourism Visiting friends/family Please tick all that apply Your personal medical historyAre you fit and well today? Yes No Details OptionalAny allergies including food, latex, medication Yes No Details OptionalHave you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before? Yes No Details OptionalTendency to faint with injections Yes No Details OptionalAny surgical operations in the past, including e.g. open-heart surgery, spleen or thymus gland removal? Yes No Details OptionalRecent chemotherapy/radiotherapy/organ transplant Yes No Details OptionalAnaemia Yes No Details OptionalBleeding /clotting disorders (including history of DVT) Yes No Details OptionalHeart disease (e.g. angina, high blood pressure) Yes No Details OptionalDiabetes Yes No Details OptionalAdditional needs and/or disability Yes No Details OptionalEpilepsy/seizures (or in a first degree relative?) Yes No Details OptionalGastrointestinal (stomach) complaints Yes No Details OptionalLiver and or kidney problems Yes No Details OptionalHIV/AIDS Yes No Details OptionalImmune system condition e.g. blood cancer Yes No Details OptionalMental health issues (including anxiety, depression) Yes No Details OptionalNeurological (nervous system) illness Yes No Details OptionalRespiratory (lung) disease Yes No Details OptionalRheumatology (joint) conditions Yes No Details OptionalSpleen problems Yes No Details OptionalAny other conditions? Yes No DetailsAre you or your partner pregnant or planning a pregnancy? Yes No Details OptionalAre you breast feeding (if applicable) Yes No Have you or anyone in your family undergone female circumcision Yes No Details OptionalAre you currently taking any medication (including prescribed, purchased or a contraceptive pill)? Yes No DetailsInformation about vaccines or malaria tablets taken in the pastPlease select all that apply Tetanus/polio/diphtheria MMR Influenza Typhoid Hepatitis A Pneumococcal Cholera Hepatitis B Meningitis Rabies Japanese encephalitis Tick borne encephalitis Yellow fever BCG Other COVID-19 (dates, brand etc.) Malaria Tablets None DetailsAny additional information Optional