Travel Questionnaire Personal Details Name * First Name Last Name Sex * Male Female Date Of Birth * - Day - Month Year Date Postcode * Daytime Tel * Email * Trip Dates Departure * Duration * Itinerary Country * Duration * Country Duration Country Duration Trip Description - please tick all appropriate boxes: Purpose of Trip: Business Pleasure Other Type of Trip: Package Self Organised Backpacking Camping Cruise Ship Trekking Accommodation Hotel Friends & Family Other Traveling Alone With Friends & Family In a group Location Type Urban Rural Altitude Activity Type Safari Adventure Other List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions) List all 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 No Does having an injection cause you to feel faint? Yes No Do you or any close family members have epilepsy? Yes No Do you have any history of mental illness including depression or anxiety? Yes No Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Yes No Have you taken out travel insurance? Yes No If you have a medical condition, have you told your insurance company about it? Yes No Are you pregnant, planning pregnancy or breast feeding? Yes No Write below any further information that might be relevant Vaccine History Have you ever had any of the following vaccinations / tablets and if so, when? Tetanus Diphtheria Hepatitis A Meningitis Influenza Jap B Enceph Malaria Tablets Polio Typhoid Hepatitis B Yellow Fever Rabies Tick Borne Other Submit Should be Empty:
