Travel Questionnaire Name Gender Male Female Date of Birth Postcode Daytime telephone number Email address Consent for storing submitted data Consent for storing submitted data Please provide details of your trip including dates and departure Departure date Duration Please list the countries to be visited and length of stay, including any stopovers? (stopovers should include short stays in airport terminals) Purpose of trip Business Pleasure Type of trip Package Self-organised Backpacking Camping Cruise ship Trekking Accommodation Hotel Friends/family Other Travelling Alone With partner In a group Location type 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) Please select the following that apply 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 Have you ever had any of the following vaccinations / tablets? Tetanus Polio Diphtheria Typhoid Hepatitis A Hepatitis B Meningitis Yellow Fever Influenza Rabies Jap B Enceph Tick Borne Malaria Tablets If you selected any of the above, please provide dates when you received/took the medication