First Name *

Surname *

Gender *

Date of Birth *

Address *

Country *

Postcode *

How many countries are you visiting?
12345

What types of places will you be staying?
Staying in a hotelStaying with friends or relativesLocal or rented accommodationStaying at a backpacker hostel or bed & breakfast accommodationCampingStaying at a refugee camp or volunteer centreStaying on a cruise shipOther

Reason for travel and activities?
Business travelHajj or other pilgrimageHolidayVisiting friends or relativesStudent gap year / backpackerAdventureVolunteer work / missionary workAdventure sports or extreme activities (for example remote trekking, motorcycling or cycling)Possibility to be sexually promiscuousTo receive medical treatmentDivingVisiting high altitude areasExpatriateRefugee / natural disasterOther activities

Are you a frequent traveller?
YesNo

Are you currently taking any prescription medications?
YesNo

Have you had a high fever or teperature in the last 24 hours?
YesNo

Are you taking any regular medication which thins your blood or prevents it from clothing excluding aspirin 75mg?
YesNo

Do you have any ongoing medical problems?
YesNo

Are you receiving dialysis?
YesNo

Do you have a bleeding disorder?
YesNo

Have you been told you may have low immunity?
YesNo

Have you had any operations in the last six months?
YesNo

Do you have or have you ever had any allergies or severe reactions to previous vaccinations or medications?
YesNo