TRAVEL QUESTIONNAIRE (ONE PER TRAVELLER)

Name………………………………………………………………………………………………………………………………....

Address……………………………………………………………………………………………………………………………….

Date of birth……………………………………Easiest daytime contact telephone number………………………………………

Date of departure_______________________________________________________________________________________

Return date or overall length of travel ______________________________________________________________________

ITINERARY
Country to be visited/Destination Length of stay Away from medical help at destination?
If so, how remote?

Please circle the descriptions that best describe your trip

1. Type of trip Business Pleasure Other

………………………………………………………………………………………………………………......................................
2. Holiday type Package Self-organised Backpacking
Camping Cruise ship Trekking
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3. Accommodation Hotel Relatives/family home Other
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4. Travelling Alone With family/friend In a group
………………………………………………………………………………………………………………......................................
5. Type of area Urban Rural Altitude
Coastal Inland Jungle
………………………………………………………………………………………………………………......................................
6. Planned activities Safari Adventure Other
………………………………………………………………………………………………………………………………………..
.
7. Will you be at any occupational risk? Yes No
………………………………………………………………………………………………………………………………………..
.
8. Will you be living or mixing closely
with local people? Yes No

Personal Medical History

Are you allergic to anything, e.g. eggs, antibiotics, nuts? ...................................................................................................................

Please list any current or repeat medications including any you buy.

………………………………………………………………………………………………………………......................................

………………………………………………………………………………………………………………......................................

Have you ever had a serious reaction to any vaccine or malaria tablets give to you before? If so please describe.

………………………………………………………………………………………………………………………………………..

Are you travelling in order to have medical, surgical or dental treatment? If so please specify.

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TRAVEL QUESTIONNAIRE CONTINUED

Have you had any other vaccinations or injections within the last 3 months? If Yes please specify.

………………………………………………………………………………………………………………………………………..

Do you or any close family member have epilepsy? Yes / No

Do you have any history of mental illness including depression or anxiety? Yes / No

Have you had any recent surgery? Yes / No

Please tick if you have, or have ever had any of the following:
Uundergone radiotherapy, chemotherapy or steroid treatment, organ transplant?
Myasthenia Gravis or other thymus problems
Removal of spleen Asthma
Heart problems High blood pressure
Kidney problems Liver problems
HIV or AIDS Diabetes
Fits or convulsions Psoriasis
Other long-term illness, please give details. ………………………………………………………………………………………

Have you taken out travel insurance? ………………………………………………

If you have a medical condition, have you informed the insurance company about this? ………………………………………

LADIES ONLY
Are you or could you be pregnant? Yes / No Are you trying to conceive? Yes / No

Are you planning pregnancy soon? Yes / No Are you breast-feeding? Yes / No

What is your type of contraception? ………………………………………………………….

VACCINATION HISTORY

Have you ever had any of the following vaccinations/malaria tablets, and if so when?

Tetanus Polio Diphtheria

Typhoid Hepatitis A Hepatitis B
Meningitis Yellow Fever Rabies
Influenza Jap B Encephalitis Tick Borne
Other …………………………………………………………………….
Malaria Tablets ………………………………………………………………………………………………………

FOR PRACTICE USE ONLY:

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