Your name *

Your email *

Your Date of Birth * dd/mm/yyyy

Contact number *

Locality *

—Please choose an option—ClackmannanshireStirlingFalkirk

Date of Departure * dd/mm/yyyy

Date of Return * dd/mm/yyyy

Please list countries you plan to visit *

Please give details of length of stay and how remote you'll be from medical help *

Reason for travel? *

—Please choose an option—BusinessPleasureOther

Please select the type of holiday *

—Please choose an option—PackageSelf-organisedBackpackingCampingCruiseTrekkingOther

Select the type of accommodation you will be staying in *

—Please choose an option—Hotel/ResortHostelCruiseRelative/Family HomeOther

The area you are staying is best described as *

—Please choose an option—Hotel/ResortUrbanRuralAltitude

Please give indication of planned activities *

—Please choose an option—No activities plannedSafariWater-sportsAdventureOther

Please detail any recent or past medical history of note below, Please include conditions such as diabetes, heart/lung conditions, Immune problems or Cancer *

Please detail any current or repeat medications *

Do you have any allergies, for example eggs, antibiotics, nuts? *

Please enter any additional information you would like to share with the Travel Health Nurse you feel will help inform the Nurse before your contacted (optional)

By submitting this form you agree this information is accurate and understand the information provided will be used to assess travel health needs. If you have not given accurate information the advice provided may be incorrect. You also agree to the NHS contacting you about your submission to arrange appointments if required.

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