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Address Required
Date of Birth Required
Sex

Please supply information about your trip in the sections below

 

Date of Departure Required
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Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip - please tick all that apply

Please supply details of your personal medical history

 

Are you fit and well today?
Any allergies including food, latex, medication?
Severe reaction to a vaccine before?
Tendency to faint with injections?
Any surgical operations in the past, including your spleen or thymus gland being removed?
Recent chemotherapy/radiotherapy/organ transplant?
Anaemia
Bleeding/clotting disorders (including history of DVT)
Heart Disease (eg. angina, high blood pressure)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal (stomach) complaints
Liver or kidney problems
HIV/AIDS
Immune system condition
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems

Women only

 

Are you pregnant/breast feeding or planning pregnancy while away?

Please supply information on any vaccines or malaria tablets taken in the past

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