Travel Questionnaire

Please complete all sections, if the form is not fully completed it may not be able to be processed. Thank you.

Personal Details

Name: *

Date of Birth: *

Daytime Tel: *

Email *

Trip Dates

Departure: *

Duration: *

Itinerary

How many countries will you be visiting during your trip? *

Country *

Duration *

Medical Help Availability *

Country *

Duration *

Medical Help Availability *

Country *

Duration *

Medical Help Availability *

Country *

Duration *

Medical Help Availability *

Trip Description

Purpose of Trip: *

Business

Pleasure

Other

Please State *

Accommodation: *

Hotel

Friends/Family

Other

Please State *

Travelling: *

Alone

With Friend/Family

In a Group

Location Type: *

Urban

Rural

Altitude

Activity *

Safari

Adventure

Other

Please State *

Personal Medical History - Please put none if no 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 or any close family members have epilepsy? *

Yes

Do you have any history of mental illness including depression or anxiety? *

Yes

Have you recently undergone radiotherapy, chemotherapy or steroid treatment? *

Yes

Are you pregnant, planning pregnancy or breast feeding?

Yes

Write below any further information that might be relevant:

Vaccination History - Please enter date where applicable

Tetanus *

Yes

Don't Know

Tetanus *

Polio *

Yes

Don't Know

Polio *

Diptheria *

Yes

Don't Know

Diptheria *

Typhoid *

Yes

Don't Know

Typhoid *

Hepatitis A *

Yes

Don't Know

Hepatitis A *

Hepatitis B *

Yes

Don't Know

Hepatitis B *

Meningitis *

Yes

Don't Know

Meningitis *

Yellow Fever *

Yes

Don't Know

Yellow Fever *

Influenza *

Yes

Don't Know

Influenza *

Rabies *

Yes

Don't Know

Rabies *

Jap B Enceph *

Yes

Don't Know

Jap B Enceph *

Tick Borne *

Yes

Don't Know

Tick Borne *

Malaria Tablets *

Yes

Don't Know

Malaria Tablets *

Other

It is YOUR responsibility to find out the Coronavirus guidelines and restrictions around vaccination and testing for the country you are visiting.
Our nursing team will not advise you with regards to coronavirus.

For more information please visit https://www.gov.uk/coronavirus

Please confirm that have read and understand it is your responsibility to find out the coronavirus regulations for the country you are visiting. *

Confirm

If you are human, leave this field blank.