Travel Questionnaire

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Personal Details
Nameyour full name
Sex
DOBof appointment
Postcodeyour full name
Daytime Telephone Numberyour full name
Trip Dates
Depature Dateof appointment
Durationyour full name
Itinerary
Country 1your full name
Durationyour full name
Availability Of Medical Helpyour full name
Country 2your full name
Durationyour full name
Availability Of Medical Helpyour full name
Country 3your full name
Durationyour full name
Availability Of Medical Helpyour full name
Country 4your full name
Durationyour full name
Availability Of Medical Helpyour full name
Country 5your full name
Durationyour full name
Availability Of Medical Helpyour full name
Trip Description - Please Tick All Appropriate Boxes
Purpose Of Trip
Type Of Trip
Accomodation
Travelling
Location Type
Activity Type
Personal Medical History
List All Chronic Medical Conditions You Have (e.g Diabetes, Heart Or Lung Conditionsmore details
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List All Allergies You Have (e.g Eggs, Nuts, Antibiotics)more details
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If You Had A Serious Reaction To A Vaccine In The Past, Which Vaccine Was It?more details
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List All Of Your Current Medications (Including Oral Contraceptive)more details
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Have You Recently Suffered From Any Infection (eg. 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 A 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 Breastfeeding?
Write Any Further Information That May Be Relevantmore details
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Vaccination History

Have You Ever Had Any Of The Following Vaccinations/Tablets? If So, Tick Where Applicable, And List When

Tetanus
When?of appointment
Polio
When?of appointment
Diptheria
When?of appointment
Typhoid
When?of appointment
Hepatitis A
When?of appointment
Hepatitis B
When?of appointment
Meningitis
When?of appointment
Yellow Fever
When?of appointment
Influenza
When?of appointment
Rabies
When?of appointment
Jap B Enceph
When?of appointment
Tick Borne
When?of appointment
Malaria Tablets
When?of appointment
Please List Any Others, Followed By The Date You Recieved Themmore details
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