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Staffa Health

Travel Form

Patient Details:

Name

Gender

Male

Female

Date of Birth

Address

City

County

Post Code

Country

Phone Number

Email Address

Departure

Duration (Days)

Please Specify Country and Stay In Each (Days)

Please Specify the Availability of Medical Health In the Country

Purpose of the Trip

Business

Pleasure

Other

Type of Trip

Package

Self-Organised

Backpacking

Camping

Cruise Ship

Trekking

Accommodation

Hotel

Friends/Family

Other

Who Are You Travelling With?

Alone

Friends/Family

In a Group

Location Type

Urban

Rural

Altitude

Activity Type

Safari

Adventure

Other

List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)

List all allergies that you have (eg. eggs, nuts, antibiotics)

If you have had a serious reaction to a vaccine in the past, which vaccine was it?

List all of your current medications (including oral contraception)

Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?

Yes

No

Does having an injection cause you to feel faint?

Yes

No

Do you or any close family members have epilepsy?

Yes

No

Do you have any history of mental illness including depression or anxiety?

Yes

No

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Yes

No

Have you taken out travel insurance?

Yes

No

If you have a medical condition, have you told your insurance company about it?

Yes

No

Are you pregnant, planning pregnancy or breast feeding?

Yes

No

Write anything below that you feel is relevant

Tetanus

Yes

No

If yes when?

Diphtheria

Yes

No

If yes when?

Hepatitis A

Yes

No

If yes when?

Meningitis

Yes

No

If yes when?

Influenza

Yes

No

If yes when?

Jap B Enceph

Yes

No

If yes when?

Malaria Tablets

Yes

No

If yes when?

Polio

Yes

No

If yes when?

Typhoid

Yes

No

If yes when?

Hepatitis B

Yes

No

If yes when?

Yellow Fever

Yes

No

If yes when?

Rabies

Yes

No

If yes when?

Tick Borne

Yes

No

If yes when?

Other

If Other, when?

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