Travel Questionnaire

Purpose of Trip:

BusinessPleasureOther

Type of Trip:

PackageSelf-OrganisedBackpackingCampingCruise ShipTrekking

Accommodation:

HotelFriends/FamilyOther

Travelling:

AloneWith Friend/FamilyIn a Group

Location Type:

UrbanRuralAltitude

Activity Type:

SafariAdventureOther

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

Have you taken out travel insurance?

Yes

If you have a medical condition, have you told your insurance company about it?

Yes

Are you pregnant, planning pregnancy or breast feeding?

Yes

Have you ever had any of the following vaccinations / tablets and if so, when?

Tetanus

Yes

Polio

Yes

Diphtheria

Yes

Typhoid

Yes

Hepatitis A

Yes

Hepatitis B

Yes

Meningitis

Yes

Yellow Fever

Yes

Influenza

Yes

Rabies

Yes

Influenza

Yes

Tick Borne

Yes

Malaria Tablets

Yes

Other: