Travel Questionnaire

Personal Details

Name: * Sex:  
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)
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5.
Purpose of Trip: Business Pleasure Other
Type of Trip: Package Self-Organised Backpacking
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)?
Does having an injection cause you to feel faint?
Do you or any close family members have epilepsy?
Do you have any history of mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance?
If you have a medical condition, have you told your insurance company about it?
Are you pregnant, planning pregnancy or breast feeding?
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 Polio
Diphtheria Typhoid
Hepatitis A Hepatitis B
Meningitis Yellow Fever
Influenza Rabies
Jap B Enceph Tick-borne Diseases
Malaria Tablets Other