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    {"id":505,"date":"2026-07-21T19:15:23","date_gmt":"2026-07-21T18:15:23","guid":{"rendered":"https:\/\/surgerywebtemp.org.uk\/f81089\/?page_id=505"},"modified":"2026-07-21T19:15:52","modified_gmt":"2026-07-21T18:15:52","slug":"travel-advice","status":"publish","type":"page","link":"https:\/\/surgerywebtemp.org.uk\/f81089\/travel-advice\/","title":{"rendered":"Travel Advice"},"content":{"rendered":"<h2>Vaccinations<\/h2>\n<p>If you&#8217;re planning to travel outside the UK, you may need to be vaccinated against some of the serious diseases found in other parts of the world.<\/p>\n<p>Our practice nurses are available by appointment to offer medical advice regarding travel and vaccinations where appropriate.<\/p>\n<p>For any private travel vaccines, such as yellow fever, you will need to attend a private travel clinic.<\/p>\n<p>Our nearest travel clinics are:-<\/p>\n<ul>\n<li><strong>MASTA Travel Clinic, 72 West Road, Shoeburyness, SS3 9DS<\/strong> &#8211;\u00a0<a href=\"https:\/\/www.masta-travel-health.com\/ClinicDetails\/513\">Clinic Details &#8211; MASTA Travel Health | For All Your Vaccination advice (masta-travel-health.com)<\/a>\\<\/li>\n<li><strong>Bansals Pharmacy, 178 The Broadway, Thorpe Bay, SS1 3ES<\/strong> &#8211;\u00a0<a href=\"https:\/\/bansalspharmacy.co.uk\/travel-clinic\">Bansals Pharmacy<\/a><\/li>\n<\/ul>\n<h3>Which vaccines do I need?<\/h3>\n<p data-block-key=\"4y7z5\">You can find out which vaccinations are necessary or recommended for the areas you&#8217;ll be visiting on these websites:<\/p>\n<ul>\n<li data-block-key=\"2155n\"><a href=\"https:\/\/travelhealthpro.org.uk\/countries\" target=\"_blank\" rel=\"noopener noreferrer\" data-link-id=\"400703\" data-use-default-display=\"false\" data-use-default-title=\"false\" data-toggle=\"tooltip\" data-placement=\"bottom\" data-bs-original-title=\"Travel Health Pro\">Travel Health Pro<\/a><\/li>\n<li data-block-key=\"2155n\"><a href=\"https:\/\/www.fitfortravel.nhs.uk\/destinations\" target=\"_blank\" rel=\"noopener noreferrer\" data-link-id=\"400704\" data-use-default-display=\"false\" data-use-default-title=\"false\" data-toggle=\"tooltip\" data-placement=\"bottom\" data-bs-original-title=\"NHS fit for Travel\">NHS fit for Travel<\/a><\/li>\n<\/ul>\n<p data-block-key=\"hglvs\">Some countries require proof of vaccination (for example, for polio or yellow fever vaccination), which must be documented on an International Certificate of Vaccination or Prophylaxis (ICVP) before you enter or when you leave a country.<\/p>\n<p data-block-key=\"hglvs\"><a href=\"https:\/\/www.nhs.uk\/conditions\/travel-vaccinations\/jabs\/\" target=\"_blank\" rel=\"noopener noreferrer\" data-link-id=\"400705\" data-use-default-display=\"false\" data-use-default-title=\"false\" data-toggle=\"tooltip\" data-placement=\"bottom\" data-bs-original-title=\"Find out more about the vaccines available for travellers abroad\">Find out more about the vaccines available for travellers abroad<\/a>.<\/p>\n<h3 id=\"mcetoc_1hchv2n8h0\">Travel Risk Assessment<\/h3>\n<p>If you are travelling abroad please complete our Travel Risk Assessment Form below\u00a0in plenty of time (We recommend 6-8 weeks) before your journey.<\/p>\n<p><a href=\"https:\/\/www.nhs.uk\/conditions\/travel-vaccinations\/\" target=\"_blank\" rel=\"noopener noreferrer\" data-link-id=\"400702\" data-use-default-display=\"false\" data-use-default-title=\"false\" data-toggle=\"tooltip\" data-placement=\"bottom\" data-bs-original-title=\"Find our more about Travel Vaccinations on nhs.uk\">Find our more about Travel Vaccinations on nhs.uk<\/a>.<\/p>\n<script>\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<\/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_13' ><div id='gf_13' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Travel Risk Assessment Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_13' id='gform_13'  action='\/f81089\/wp-json\/wp\/v2\/pages\/505#gf_13' data-formid='13' novalidate>\n        <div id='gf_progressbar_wrapper_13' 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'>4<\/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_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_13_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_13' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_3\" class=\"gfield nhsuk-form-group gfield--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_13_3'>\n                            \n                            <span id='input_13_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_13_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_13_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_13_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_13_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_13_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_13_4_2_container'><label for='input_13_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_13_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_13_4_1_container'><label for='input_13_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_13_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_13_4_3_container'><label for='input_13_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_13_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_13_5\" class=\"gfield nhsuk-form-group gfield--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_13_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_13_5' type='email' value='' class='large nhsuk-input '    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_13_6\" class=\"gfield nhsuk-form-group gfield--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_13_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_13_6' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_13_8' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_2' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_2' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_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_13_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_13_9_2_container'><label for='input_13_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_13_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_13_9_1_container'><label for='input_13_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_13_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_13_9_3_container'><label for='input_13_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_13_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_13_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_13_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_13_10_2_container'><label for='input_13_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_13_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_13_10_1_container'><label for='input_13_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_13_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_13_10_3_container'><label for='input_13_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_13_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_13_11\" class=\"gfield nhsuk-form-group gfield--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_13_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_13_11' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_13_12\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_12_0' id='label_13_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_13_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_13_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_12_1' id='label_13_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_13_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_13_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_12_2' id='label_13_12_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_13_13\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_13_0' id='label_13_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_13_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_13_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_13_1' id='label_13_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_13_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_13_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_13_2' id='label_13_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_13_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_13_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_13_3' id='label_13_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_13_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_13_13_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_13_4' id='label_13_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_13_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_13_13_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_13_5' id='label_13_13_5' class='gform-field-label gform-field-label--type-inline'>Trekking<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_13_14\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_14_0' id='label_13_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_13_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_13_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_14_1' id='label_13_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_13_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_13_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_14_2' id='label_13_14_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_13_15\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_15_0' id='label_13_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_13_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_13_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_15_1' id='label_13_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_13_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_13_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_15_2' id='label_13_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_13_16\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_16_0' id='label_13_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_13_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_13_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_16_1' id='label_13_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_13_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_13_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_16_2' id='label_13_16_2' class='gform-field-label gform-field-label--type-inline'>Altitude<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_13_17\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_17_0' id='label_13_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_13_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_13_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_17_1' id='label_13_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_13_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_13_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_17_2' id='label_13_17_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_18' class='nhsuk-button nhsuk-button--reverse gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_13_18' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_3' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_3' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_19\" class=\"gfield nhsuk-form-group gfield--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_13_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_13_19' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_20\" class=\"gfield nhsuk-form-group gfield--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_13_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_13_20' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_21\" class=\"gfield nhsuk-form-group gfield--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_13_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_13_21' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_13_22\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_22_0' id='label_13_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_13_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_13_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_22_1' id='label_13_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_13_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_13_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_22_2' id='label_13_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_13_23\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_23_0' id='label_13_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_13_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_13_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_23_1' id='label_13_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_13_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_13_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_23_2' id='label_13_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_13_24\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_24_0' id='label_13_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_13_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_13_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_24_1' id='label_13_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_13_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_13_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_24_2' id='label_13_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_13_25\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_25_0' id='label_13_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_13_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_13_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_25_1' id='label_13_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_13_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_13_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_25_2' id='label_13_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_13_26\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_26_0' id='label_13_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_13_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_13_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_26_1' id='label_13_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_13_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_13_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_26_2' id='label_13_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_13_27\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice 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_13_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_13_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_27_0' id='label_13_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_13_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_13_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_27_1' id='label_13_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_13_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_13_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_13_27_2' id='label_13_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_13_28\" class=\"gfield nhsuk-form-group gfield--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_13_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_13_28' class='textarea nhsuk-textarea  medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_13_29\" class=\"gfield nhsuk-form-group gfield--type-checkbox gfield--type-choice 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_13_29'><div class='gchoice nhsuk-checkboxes__item gchoice_13_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_13_29_1'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_13_29_1' id='label_13_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_13_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_13_29_2'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_13_29_2' id='label_13_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_13_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_13_29_3'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_13_29_3' id='label_13_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_13_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_13_29_4'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_13_29_4' id='label_13_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_13_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_13_29_5'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_13_29_5' id='label_13_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_13_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_13_29_6'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_13_29_6' id='label_13_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_13_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_13_29_7'   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