Pre-Travel Questionnaire

First Name *
Family Name *
Gender
Photo Upload
Nationality
Date of Birth
Address
Email
Mobile
Landline
Occupation
What is the purpose of your trip?
If trip is work related please give details

How will you travel to your destination?

Plane

Sea

Bus

Train

Other

What type of transport do you expect to use while abroad?

	Car		Bus		Train
	Motorcycle / Scooter		Bicycle		Other

What type of accommodation will you stay at during your trip?

	Hotel	Apartment	Hostel
	Camping	Motor home	Other
If yes, please provide details

Are you planning any sporting activities on your trip?

Yes

If yes, please give details

Do you have any of the following conditions and if so please give details?

Diabetes	Heart Disease	Stroke	High Blood Pressure
Cancer	Arthritis	Kidney	Kidney Failure
Vascular Disease	Skin Disease	Deafness	Visual Impairment
Other

Please answer yes or no to the following questions.	Yes	No	If yes please give details.
1. Have you been hospitalised in the past year?
2. Are you taking any medication?
3. Do you have any allergies?
4. Do you smoke?
5. Do you drink alcohol?
6. Do you take exercise?
7. Are you pregnant?

Please indicate if you have had the following vaccinations and the approximate date of vaccination if known

Vaccine	Date of vaccination	Vaccine	Date of vaccination
Hepatitis A		Polio
Hepatitis B		Tetanus
Typhoid		BCG
Yellow Fever		Diphtheria
Japanese Enceph B		Rabies

Thank you for completing this questionnaire which will allow us to ensure that you have a safe and enjoyable trip.
A member of our nursing team will be in contact with you shortly, please press Submit.

Please list all countries to be visited including stopovers which should include stays in airport terminals.
Country	City	Rural	Coast	Length of stay





For additional information should you be travelling to 6 or more countries please list them here