Travel Questionnaire

Personal Details

Name:	*	Sex:	Female Male
Date of Birth:	* (dd/mm/yyyy)
Daytime Tel:		Email:

Date of Trip

Departure Date:	(dd/mm/yyyy)
Length of Visit:

* Mandatory field

Countries to be Visited

	Country	Length of Stay	Availability of Medical Help (i)
1.
2.
3.
4.
5.

Purpose of Trip:	Business	Pleasure	Other
Type of Trip:	Package	Self-Organised	Backpacking
Type of Trip:	Camping	Cruise Ship	Trekking
Accommodation:	Hotel	Friends/Family	Other
Travelling:	Alone	With Friend/Family	In a Group
Location Type:	Urban	Rural	Altitude (i)
Activity Type:	Safari	Adventure	Other

(Please tick all appropriate boxes)

Personal Medical History

List all the serious medical conditions you have (eg. diabetes, heart or lung conditions)
List all the allergies that you have (eg. eggs, nuts, antibiotics)
If you have had a serious reaction to a vaccine in the past, which vaccine was it?
List all of your current medications (including oral contraception)
Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?	Yes
Does having an injection cause you to feel faint?	Yes
Do you or any close family members have epilepsy?	Yes
Do you have any history of mental illness including depression or anxiety?	Yes
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?	Yes
Have you taken out travel insurance?	Yes
If you have a medical condition, have you told your insurance company about it?	Yes
Are you pregnant, planning pregnancy or breast feeding?	Yes
Write below any further information that might be relevant

Vaccination History

Have you ever had any of the following vaccinations / tablets and if so, when?

Tetanus	Yes	Polio	Yes
Diphtheria	Yes	Typhoid	Yes
Hepatitis A	Yes	Hepatitis B	Yes
Meningitis	Yes	Yellow Fever	Yes
Influenza	Yes	Rabies	Yes
Jap B Enceph	Yes	Tick-borne Diseases	Yes
Malaria Tablets	Yes	Other

Important Disclaimer: Please note that any information submitted using this form will be sent to the Practice by an unencrypted e-mail message. This means that someone else outside the Practice could possibly access and read it. Please contact us if you would like to find out about other ways to send us this information.