Tree View Designs

Travel Questionnaire

Personal details Full name: *

Title: *

Gender: *

Date of birth: *

Post code: *

Contact no: *

Email address: *

Trip dates

Departure: *

Duration: *

Itinerary

* Availability of medical help: If you will be travelling to a place where medical help is not readily on hand, estimate how long it would take to reach a doctor.

Country: *

Duration: *

Availability of medical help:

ADD COUNTRY

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)?

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?

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Have you taken out travel insurance?

If you have a medical condition, have you told your insurance company about it?

Are you pregnant, planning pregnancy or breast feeding?

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:

When:

Diphtheria:

When:

Hepatitis A:

When:

Meningitis:

When:

Influenza:

When:

Jap B Enceph:

When:

Malaria tablets:

When:

Polio:

When:

Typhoid:

When:

Hepatitis B:

When:

Yellow fever:

When:

Rabies:

When:

Tick borne:

When:

Other: