Travel Questionnaire

Personal Details
Name
Sex
- Male
- Female
Date of birth
Day
Month
Year
Postcode
Phone
Email
Trip Dates
Date of Departure
DD slash MM slash YYYY
Date of Return
DD slash MM slash YYYY
Holiday Itinerary
Country Duration Availability of Medical Help
Country Duration Availability of Medical Help
If you are going to more than three countries please click the plus icon for more input lines.
Country Duration Availability of Medical Help

If you are going to more than three countries please click the plus icon for more input lines.
Trip Description
Purpose 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 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 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
Tetanus
- 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

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Monday 19 September bank holiday – GP practice closureSeptember 12, 2022 - 2:05 pm
Why does the receptionist need to ask what’s wrong with me?March 10, 2022 - 4:35 pm
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COVID vaccination certificationMay 14, 2021 - 9:40 am

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Monday:	8:00am– 6:30pm
Tuesday:	8:00am–6:30pm
Wednesday:	8:00am–6:30pm
Thursday:	8:00am–6:30pm
Friday:	8:00am–6:30pm
Weekend:	Closed
Bank Holidays:	Closed

Travel Questionnaire

Personal Details

Trip Dates

Holiday Itinerary

Trip Description

Personal Medical History

Vaccination History

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Country	Duration	Availability of Medical Help

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