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    {"id":478,"date":"2026-01-13T15:50:08","date_gmt":"2026-01-13T15:50:08","guid":{"rendered":"https:\/\/surgerywebtemp.org.uk\/c82009\/?page_id=478"},"modified":"2026-01-13T15:50:08","modified_gmt":"2026-01-13T15:50:08","slug":"travel-risk-assessment","status":"publish","type":"page","link":"https:\/\/surgerywebtemp.org.uk\/c82009\/travel-risk-assessment\/","title":{"rendered":"Travel Risk Assessment"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_14' ><div id='gf_14' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_14' id='gform_14'  action='\/c82009\/wp-json\/wp\/v2\/pages\/478#gf_14' data-formid='14' novalidate>\n        <div id='gf_progressbar_wrapper_14' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_14_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_14' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_30\" class=\"gfield nhsuk-form-group gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_30'>Please select your practice:&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_14_30' class='large gfield_select nhsuk-select '    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select...<\/option><option value='Market Harborough Medical Centre &amp; St Lukes Branch Surgery' >Market Harborough Medical Centre &amp; St Lukes Branch Surgery<\/option><option value='Husbands Bosworth Medical Centre' >Husbands Bosworth Medical Centre<\/option><\/select><\/div><\/div><fieldset id=\"field_14_3\" class=\"gfield nhsuk-form-group gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' >Name&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_14_3'>\n                            \n                            <span id='input_14_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_3.3' id='input_14_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_14_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_14_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_3.6' id='input_14_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_14_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_14_4\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Date of Birth&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_14_4' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_14_4_2_container'><label for='input_14_4_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_14_4_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_14_4_1_container'><label for='input_14_4_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_14_4_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_14_4_3_container'><label for='input_14_4_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_14_4_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_14_5\" class=\"gfield nhsuk-form-group gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_5'>Email&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_14_5' type='email' value='' class='large nhsuk-input '    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_14_6\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_6'>Phone Number&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_14_6' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_9\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Date of Departure&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_14_9' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_14_9_2_container'><label for='input_14_9_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_14_9_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_14_9_1_container'><label for='input_14_9_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_14_9_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_14_9_3_container'><label for='input_14_9_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_14_9_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_14_10\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Date of Return&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_14_10' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_14_10_2_container'><label for='input_14_10_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_14_10_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_14_10_1_container'><label for='input_14_10_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_14_10_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_14_10_3_container'><label for='input_14_10_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_14_10_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_14_11\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_11'>Please give details of country to be visited, length of stay, and how remote you\u2019ll be from medical help&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_14_11' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_14_12\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Type of trip&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_12' type='radio' value='Business'  id='choice_14_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_12_0' id='label_14_12_0' class='gform-field-label gform-field-label--type-inline'>Business<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_12' type='radio' value='Pleasure'  id='choice_14_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_12_1' id='label_14_12_1' class='gform-field-label gform-field-label--type-inline'>Pleasure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_12' type='radio' value='Other'  id='choice_14_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_12_2' id='label_14_12_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_13\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Holiday type&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Package'  id='choice_14_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_13_0' id='label_14_13_0' class='gform-field-label gform-field-label--type-inline'>Package<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Self organised'  id='choice_14_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_13_1' id='label_14_13_1' class='gform-field-label gform-field-label--type-inline'>Self organised<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Backpacking'  id='choice_14_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_13_2' id='label_14_13_2' class='gform-field-label gform-field-label--type-inline'>Backpacking<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Camping'  id='choice_14_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_13_3' id='label_14_13_3' class='gform-field-label gform-field-label--type-inline'>Camping<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_13_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Cruise ship'  id='choice_14_13_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_13_4' id='label_14_13_4' class='gform-field-label gform-field-label--type-inline'>Cruise ship<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_13_5'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Trekking'  id='choice_14_13_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_13_5' id='label_14_13_5' class='gform-field-label gform-field-label--type-inline'>Trekking<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_14\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Accommodation&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='Hotel'  id='choice_14_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_14_0' id='label_14_14_0' class='gform-field-label gform-field-label--type-inline'>Hotel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='Relatives\/family home'  id='choice_14_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_14_1' id='label_14_14_1' class='gform-field-label gform-field-label--type-inline'>Relatives\/family home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='Other'  id='choice_14_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_14_2' id='label_14_14_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_15\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Travelling&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_15' type='radio' value='Alone'  id='choice_14_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_15_0' id='label_14_15_0' class='gform-field-label gform-field-label--type-inline'>Alone<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_15' type='radio' value='With family\/friend'  id='choice_14_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_15_1' id='label_14_15_1' class='gform-field-label gform-field-label--type-inline'>With family\/friend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_15' type='radio' value='In a group'  id='choice_14_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_15_2' id='label_14_15_2' class='gform-field-label gform-field-label--type-inline'>In a group<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_16\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Staying in area which is&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Urban'  id='choice_14_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_16_0' id='label_14_16_0' class='gform-field-label gform-field-label--type-inline'>Urban<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Rural'  id='choice_14_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_16_1' id='label_14_16_1' class='gform-field-label gform-field-label--type-inline'>Rural<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Altitude'  id='choice_14_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_16_2' id='label_14_16_2' class='gform-field-label gform-field-label--type-inline'>Altitude<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_17\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Planned activities&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='Safari'  id='choice_14_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_17_0' id='label_14_17_0' class='gform-field-label gform-field-label--type-inline'>Safari<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='Adventure'  id='choice_14_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_17_1' id='label_14_17_1' class='gform-field-label gform-field-label--type-inline'>Adventure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='Other'  id='choice_14_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_17_2' id='label_14_17_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_14_19\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_19'>Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_14_19' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_14_20\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_20'>List any current or repeat medications&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_14_20' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_14_21\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_21'>Do you have any allergies for example to eggs, antibiotics, nuts?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_14_21' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_14_22\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Have you ever had a serious reaction to a vaccine given to you before?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_22' type='radio' value='Yes'  id='choice_14_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_22_0' id='label_14_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_22' type='radio' value='No'  id='choice_14_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_22_1' id='label_14_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_22' type='radio' value='Don&#039;t know'  id='choice_14_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_22_2' id='label_14_22_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_23\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Does having an injection make you feel faint?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_23' type='radio' value='Yes'  id='choice_14_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_23_0' id='label_14_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_23' type='radio' value='No'  id='choice_14_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_23_1' id='label_14_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_23' type='radio' value='Don&#039;t know'  id='choice_14_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_23_2' id='label_14_23_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_24\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you or any close family members have epilepsy?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_24' type='radio' value='Yes'  id='choice_14_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_24_0' id='label_14_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_24' type='radio' value='No'  id='choice_14_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_24_1' id='label_14_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_24' type='radio' value='Don&#039;t know'  id='choice_14_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_24_2' id='label_14_24_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_25\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have any history or mental illness including depression or anxiety?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='Yes'  id='choice_14_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_25_0' id='label_14_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='No'  id='choice_14_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_25_1' id='label_14_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='Don&#039;t know'  id='choice_14_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_25_2' id='label_14_25_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_26\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Have you recently undergone radiotherapy, chemotherapy or steroid treatment?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='Yes'  id='choice_14_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_26_0' id='label_14_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='No'  id='choice_14_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_26_1' id='label_14_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='Don&#039;t know'  id='choice_14_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_26_2' id='label_14_26_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_27\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='Yes'  id='choice_14_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_27_0' id='label_14_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='No'  id='choice_14_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_27_1' id='label_14_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='Don&#039;t know'  id='choice_14_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_27_2' id='label_14_27_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_14_28\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_28'>Please type below any further information which may be relevant&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_14_28' class='textarea nhsuk-textarea  medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_14_29\" class=\"gfield nhsuk-form-group gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' >Have you ever had any of the following vaccinations \/ malaria tablets?&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox nhsuk_checkbox ' id='input_14_29'><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.1' type='checkbox'  value='Tetanus'  id='choice_14_29_1'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_1' id='label_14_29_1' class='gform-field-label gform-field-label--type-inline'>Tetanus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.2' type='checkbox'  value='Polio'  id='choice_14_29_2'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_2' id='label_14_29_2' class='gform-field-label gform-field-label--type-inline'>Polio<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.3' type='checkbox'  value='Diptheria'  id='choice_14_29_3'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_3' id='label_14_29_3' class='gform-field-label gform-field-label--type-inline'>Diptheria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.4' type='checkbox'  value='Typhoid'  id='choice_14_29_4'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_4' id='label_14_29_4' class='gform-field-label gform-field-label--type-inline'>Typhoid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.5' type='checkbox'  value='Hepatitis A'  id='choice_14_29_5'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_5' id='label_14_29_5' class='gform-field-label gform-field-label--type-inline'>Hepatitis A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.6' type='checkbox'  value='Hepatitis B'  id='choice_14_29_6'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_6' id='label_14_29_6' class='gform-field-label gform-field-label--type-inline'>Hepatitis B<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.7' type='checkbox'  value='Meningitis'  id='choice_14_29_7'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_7' id='label_14_29_7' class='gform-field-label gform-field-label--type-inline'>Meningitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.8' type='checkbox'  value='Yellow Fever'  id='choice_14_29_8'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_8' id='label_14_29_8' class='gform-field-label gform-field-label--type-inline'>Yellow Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.9' type='checkbox'  value='Rabies'  id='choice_14_29_9'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_9' id='label_14_29_9' class='gform-field-label gform-field-label--type-inline'>Rabies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.11' type='checkbox'  value='Jap B Enceph'  id='choice_14_29_11'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_11' id='label_14_29_11' class='gform-field-label gform-field-label--type-inline'>Jap B Enceph<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.12' type='checkbox'  value='Tick Borne'  id='choice_14_29_12'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_12' id='label_14_29_12' class='gform-field-label gform-field-label--type-inline'>Tick Borne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_29_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.13' type='checkbox'  value='Other\/Malaria tablets'  id='choice_14_29_13'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_29_13' id='label_14_29_13' class='gform-field-label gform-field-label--type-inline'>Other\/Malaria tablets<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_14_1' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div 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