Enquiry Form

         
  Surname Date of Birth
  Forename Address
  Telephone Mobile
  Fax E-mail Address
         
  This section to be filled by patient
  Destinations/accommodation (including all countries. eg. stopovers)
 
Destination town / country Length of stay
Weeks/days
Reason For Visit Hotels Relatives/
Friends
Camping Altitude
(If known)
             
             
             
             
             
             
         
  Previous immunisation history, with details if known:
 
  Required If not when were you last immunised?   Required If not when were you last immunised?
Hepatitis A(1st dose)
Yes No
Hepatitis A(Booster)
Yes No
           
Hepatitis B (1st dose)
Yes No
Hepatitis B (2nd dose)
Yes No
           
Hepatitis B (3rd dose)
Yes No
Tetanus
Yes No
           
Typhoid
Yes No
Meningitis
Yes No
           
Yellow Fever
Yes No
Polio
Yes No
           
Other
Yes No
           
         
  This section to be filled by patient
  Relevant medical conditions/ current medication (including contraception)
   
         
  Known allergies
         
  Pregnant
Yes No
   
  Do you have a history of depression or psychiatric illness?
Yes No