Travel Vaccination Questionnaire Consent for storing submitted data Consent for storing submitted data Forname(s) Surname Contact Number Email What is the main purpose of your trip? Holiday Work Other If Other Please detail below Will you be staying anywhere other than a hotel, resort or cruise ship? Yes If Yes please detail below Will you be visiting rural or remote areas? Yes No Have you had any travel vaccinations before? Yes No If Yes: please tell us which vaccines and approximate dates, if known. Do you have any allergies or have you ever had a serious reaction to a vaccine? Yes No If Yes: please provide details. Do you take any regular medication? Yes No If yes please list below Are you pregnant, breastfeeding or trying to become pregnant? Yes No Not Applicable