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 Details

    Trip Dates

    Itinerary
    Country Duration Availability of Medical Help

    Trip Description - please tick all appropriate boxes/b>
    Purpose of Trip: Business Pleasure Other
    Type of Trip: Package Self Organiusaed Backpacking
    Camping Cruise Ship
    Accomodation 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 (e.g. diabetes, heart or lung conditions)

    List all allergies that you have (e.g. 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 infecxtion (e.g. heavy cold, flu or high temeprature)

    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? 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

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