Travel Questionnaire

Personal details
Trip dates
Itinerary

* Availability of medical help: If you will be travelling to a place where medical help is not readily on hand, estimate how long it would take to reach a doctor.

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Trip description (please tick all appropriate boxes)

Purpose of trip:

Type of trip:

Accommodation:

Travelling:

Location type:

Activity type:

Personal medical history
Vaccination history

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