Secure Surgery Website - Travel Questionnaire

Forename. *

Middle Names.

Surname. *

Sex.

Male

Female

Date of Birth. *

Format: dd/mm/yyyy

Easiest Contact Telephone Number.

E-mail address.

Date of Departure. *

Format: dd/mm/yyyy

Return Date. *

Format: dd/mm/yyyy

Please list the countries you will be visiting and also state the length of stay at each. *

Type of Trip.

Business

Pleasure

Other

Holiday Type.

Package

Self Organised

Backpacking

Camping

Cruise Ship

Accomodation.

Hotel

Relatives/Family Home

Other

Travelling.

Along

With Family / Friend

In A Group

Staying in an area which is.

Urban

Rural

Altitude

Planned Activities.

Safari

Adventure

Other

Do you have any recent or past medical history? (including diabetes, heart or lung conditions).

List any current or repeat medications.

Do you have any allergies for example to eggs, antibiotics, nuts?.

Have you ever had a serious reaction to a vaccine given to you before? (If yes please state which one).

Does having an injection make you feel faint?.

Yes

No

Do you or any close family members have epilepsy?.

Yes

No

Do you have any history of mental illness including depression or anxiety?.

Yes

No

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?.

Yes

No

Women only: Are you pregnant or planning pregnancy or breast feeding?.

Yes

No

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?.

Yes

No

Please write below any further information which may be relevant to your medical history.

Have you ever had any of the following vaccinations / malaria tablets?.

Tetanus

Typhoid

Meningitis

Rabies

Polio

Hepatitis A

Yellow Fever

Jap B Enceph

Diphtheria

Hepatitis B

Influenza

Tick Borne

Malaria tablets

Other