Travel Questionnaire

About This Form

Fields marked with a red asterisk are
compulsory.

Please fill out this form. We will confirm the accuracy of the details when you attend your appointment.

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Personal Details
Name:			Sex: Female Male
Date of Birth:		Postcode:
Daytime Tel:
Email:
Trip Dates
Departure:		Duration:
Itinerary
Country		Duration	Availability of Medical Help





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
Travelling:	Alone With Friend/Family In a Group
Location Type:	Urban Rural Altitude
Activity Type:	Safari Adventure Other
Personal Medical History
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
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	Yes
Malaria Tablets	Yes	Other