1) Name :
2) Date of Birth : 3) Address 4) Travel Destination 5) I will leave the UK on the following date and will return from my destination on . . . 6) In the past I have taken the following anti-malarial drugs.... Did you have any problems with the medication ? Yes No If Yes what were the sideffects? 7) Current medication None 8) Current allergies None 9) Past Medical history None 10)Request i) a travellers tummy kit Yes No ii) Anti-malarial drugs Yes No iii) Number One Medical Kit Yes No 11 ) Ideal delivery times
