PRE-TRAVEL QUESTIONNAIRE

TRAVEL DETAILS

UrbanRural BusinessLeisure
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UrbanRural BusinessLeisure

TYPE OF ACCOMMODATION

HotelSelf CateringCampingFriends/RelativesConstruction CampOther

ACTIVITIES

ClimbingDivingPiloting an AircraftOther
Work at heightsOperate MachineryHave exposure to animalsOther

MEDICAL HISTORY

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

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YesNo
YesNo
YesNo

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