Personal Details
Name
*
First Name
Last Name
Sex
*
Male
Female
Date Of Birth
*
-
Day
-
Month
Year
Date
Postcode
*
Daytime Tel
*
Email
*
Trip Dates
Departure
*
Duration
*
Itinerary
Country
*
Duration
*
Country
Duration
Country
Duration
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
Traveling
Alone
With Friends & Family
In a group
Location Type
Urban
Rural
Altitude
Activity Type
Safari
Adventure
Other
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
No
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
Vaccine History
Have you ever had any of the following vaccinations / tablets and if so, when?
Tetanus
Diphtheria
Hepatitis A
Meningitis
Influenza
Jap B Enceph
Malaria Tablets
Polio
Typhoid
Hepatitis B
Yellow Fever
Rabies
Tick Borne
Other
Submit
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