Travel Questionnaire

Personal Details

Gender: *

Trip Dates

Itinerary

Country *
Duration *
Availability of Medical Help
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Trip Description

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?
Tetanus
Polio
Diphtheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Malaria Tablets
Fields marked with an asterisk (*) are mandatory