Pre-Travel Questionnaire
Please list all countries to be visited including stopovers which should include stays in airport terminals.
Country City Rural Coast Length of stay

For additional information should you be travelling to 6 or more countries please list them here

How will you travel to your destination?

Plane Sea Bus Train Other

What type of transport do you expect to use while abroad?

Car Bus Train
Motorcycle / Scooter Bicycle Other

What type of accommodation will you stay at during your trip?

Hotel Apartment Hostel
Camping Motor home Other
If yes, please provide details
Yes No If yes, please give details

Do you have any of the following conditions and if so please give details?

Diabetes Heart Disease Stroke High Blood Pressure
Cancer Arthritis Kidney Kidney Failure
Vascular Disease Skin Disease Deafness Visual Impairment
Please answer yes or no to the following questions. Yes No If yes please give details.

Please indicate if you have had the following vaccinations and the approximate date of vaccination if known

Vaccine Date of vaccination Vaccine Date of vaccination
Hepatitis A Polio
Hepatitis B Tetanus
Typhoid BCG
Yellow Fever Diphtheria
Japanese Enceph B Rabies

Thank you for completing this questionnaire which will allow us to ensure that you have a safe and enjoyable trip.
A member of our nursing team will be in contact with you shortly, please press Submit.