Travel Questionnaire Personal DetailsName Sex Male Female Date of birth Day Month Year Postcode PhoneEmail Trip DatesDate of Departure DD slash MM slash YYYY Date of Return DD slash MM slash YYYY Holiday ItineraryCountryDurationAvailability of Medical HelpCountryDurationAvailability of Medical HelpIf you are going to more than three countries please click the plus icon for more input lines.CountryDurationAvailability of Medical Help If you are going to more than three countries please click the plus icon for more input lines.Trip DescriptionPurpose of Trip Business Pleasure Other Type of Trip Package Holiday Self-Organised Backpacking Trekking Camping Cruise Purpose of Trip Business Pleasure Other Accommodation Hotel Friends/Family Other Travelling On my own With Friend/Family In a Group Location Urban Rural Altitude Activity Type Safari Adventure Other Personal Medical HistoryList 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 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 relevantVaccination HistoryTetanus Yes No Date Day Month Year Diphtheria Yes No Date Day Month Year Hepatitis A Yes No Date Day Month Year Hepatitis B Yes No Date Day Month Year Polio Yes No Date Day Month Year Typhoid Yes No Date Day Month Year Meningitis Yes No Date Day Month Year Yellow Fever Yes No Date Day Month Year Influenza Yes No Date Day Month Year Rabies Yes No Date Day Month Year Jap B Enceph Yes No Date Day Month Year Tick Borne Yes No Date Day Month Year Malaria Tablets Yes No Date Day Month Year
