Travel Questionnaire Travel Questionnaire MKII Personal Details Full Name * Date of Birth * Sex * Male Female Postcode * Contact Number * Email Address * Confirm Email Address * Trip Dates Departure * Duration * Itinerary Country * Duration * Availability of Medical Help * plus1 Add minus1 Remove Trip Description Please tick all appropriate boxes Purpose of Trip * Business Pleasure Other Type of Trip * Package Self-Organised Backpacking Camping Cruise Ship Trekking Accommodation * 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) List all of your current medications * (including oral contraception) If you have had a serious reaction to a vaccine in the past, which vaccine was it? * Have you recently suffered from any infection? * Yes No (e.g heavy cold, flu or high temperature) Does having an injection cause you to feel faint? * Yes No Do you or any close family members have epilepsy? * Yes No Do you have any history of mental illness including depression or anxiety? * Yes No Have you recently undergone radiotherapy, chemotherapy or steroid treatment? * Yes No Have you taken out travel insurance? * Yes No If you have a medical condition, have you told your insurance company about it? * Yes No Are you pregnant, planning pregnancy or breast feeding? * Yes No 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 No If ‘yes’, when? Diphtheria * Yes No If ‘yes’, when? Hepatitis A * Yes No If ‘yes’, when? Meningitis * Yes No If ‘yes’, when? Influenza * Yes No If ‘yes’, when? Jap B Enceph * Yes No If ‘yes’, when? Malaria Tablets * Yes No If ‘yes’, when? Polio * Yes No If ‘yes’, when? Typhoid * Yes No If ‘yes’, when? Hepatitis B * Yes No If ‘yes’, when? Yellow Fever * Yes No If ‘yes’, when? Rabies * Yes No If ‘yes’, when? Tick Borne * Yes No If ‘yes’, when? Other Submit