PRE-TRAVEL QUESTIONNAIRE

    TRAVEL DETAILS

    UrbanRural

    BusinessLeisure

    Add Additional Field

    UrbanRural

    BusinessLeisure

    TYPE OF ACCOMMODATION

    HotelSelf CateringCampingFriends/RelativesConstruction CampOther

    ACTIVITIES

    ClimbingDivingPiloting an AircraftOther

    Work at heightsOperate MachineryHave exposure to animalsOther

    MEDICAL HISTORY

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo


    ARE YOU ALLERGIC TO ANY OF THE FOLLOWING: If YES, please provide complete details

    YesNo

    YesNo

    YesNo

    YesNo

    IMMUNIZATIONS - If you had a reaction to any immunization, please state which and nature of reaction