Travel Questionnaire

Personal Details

Required
Date of Birth Required
Required
Required
Required

Trip Dates and Details

Required
Required
Purpose of Trip:
Type of Trip
Accommodation
Traveling
Location Type
Activity Type

Health Information

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?

Vaccine History

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

Required