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Personal Details Name : * Date of Birth :

dd/mm/year *

Male : Female :

Address : E-mail Address : * Phone Number : *

Dates of Trip Date of Departure :

dd/mm/year * Return date or overall
length of trip :

dd/mm/year *

Itinerary and purpose of visit Country to be Visited Length of Stay Away from medical help at destination, if so, how remote? 1 2 3 4
(Other Countries)

Please tick as appropriate below to best describe your trip Type of trip : Business Pleasure Other

Holiday type : Package Self Organised Backpacking

Camping Cruise ship Trekking

Accommodation :
   Hotel
   Relatives /
      family home Other

Travelling :
   Alone
   With family /
      friend In a Group

Staying in areawhich is: Urban Rural Altitude

Personal medical history 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? Doeshaving an injection make you feel feint? Do you or any close family members have epilepsy? Do you have any history or mental illness including depression oranxiety Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Women only: Areyou pregnant or planning pregnancy or breast feeding? Have you taken out travel insurance and if you have a medicalcondition, informed the insurance company about his? Please write below any further information which may berelevant

Vaccination History Have you ever had any of the following vaccinations / malaria tablets and if so when? Tetanus
      / mm/yy Polio
      / mm/yy Diphtheria
      / mm/yy Typhoid
      / mm/yy Hepatitis A
      / mm/yy Hepatitis B
      / mm/yy Meningitis
      / mm/yy Yellow Fever A
      / mm/yy Influenza
      / mm/yy Rabies
      / mm/yy Jap B Enceph
      / mm/yy Tick Borne
      / mm/yy Other : Malaria tablets : Security Code : This Is CAPTCHA Image

Why am I asked to enter this code? *

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