TRAVELLER HISTORY FORM

Personal Information

Travel Details

Countries Departure Length of Stay Type of area to be visited Reason for Travel
Urban Rural Business Leisure
















Type of accomodation
Activities Climbing / Diving / Piloting an aircraft yes no Do you work at heights, operate machinery or have exposure to animals? yes no

Medical History

yes no
Medical History
Epilepsy
Asthma
Blood Disorder
Thymus Gland Conditions – Myasthenia Gravis
Psychiatric Disorder
Cancer
Cardiac Disorder/ Hypertension
Guillain-Barre syndrome/ Multiple Sclerosis
Kidney Problems
Details
Psoriasis
Porhyria
Hepatitis
Removal of Spleen
Other Surgery
Have you:
Lost more than 5kg in the past 12 months
Are you pregnant
On any Medication

Allergies

yes no
Eggs/chicken
Antibiotics
Anti-malarial Drugs
Sulphonamides
Other

Immunizations

History

When were you last immunized? DATE DATE
Tetanus Japanese B Encephelopathy
Cholera Hepatitis A
Diphteria Hepatitis B
Typhoid Meningitis
Yellow Fever Other
Have you had any reactions to Immunizations? yes no

Required for travel

Date