Travel Questionnaire

Name

Gender

Male

Female

Date of Birth

Postcode

Daytime telephone number

Email address

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

If you selected any of the above, please provide dates when you received/took the medication