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
Hotel
Self Catering
Camping
Relatives/Friends
Construction Camp
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
SUBMIT