Travel Health Questionnaire 


 The travel health questionnaire is used by travel agencies, they collect both post travel health questionnaire, pre-travel health questionnaire of people how often travel. People travel for different needs and it’s the responsibility of travel agency's to collect travelers health questionnaire. This could help the travel agency as well as the customers. With the health of this questionnaire the travel agency's can provide travelers health advice.

Most of the people according to research suffer from travel phobia, which causes vomitings and sleepiness. The travel agency can take many preventive measures. A travel health questionnaire can be used by organizations, medical institutions, travel agencies, insurance companies and related organizations for information related to health issues of the individual and the current health conditions. Depending on requirements, a health questionnaire travel can be highly detailed in nature or simply accurate and concise. The information received from a travel health questionnaire is used for record keeping or for use by different organizations to customize health insurance coverage.

Questionnaire About Travel Health


 Participant Name: 
Current number of insurance policy: 
Date of Departure:  Location: 
Date of Birth: (MM / DD / YY) Gender: (H / F)
Address: City: 
State: Zip Code: 
Email: 
Phone Number:

 When have you take your last medical check?
a) Some days ago
b) A week back
c) several weeks ago
d) A month back
e) A few months back
f) past 6 months
g) last year
h) Not remembering

 Travel plans are one of the following activities?

 Potential sex contacts
Piercing / Tattoos
rural destinations
Farm or Safari Destination
Contact with animals
Visiting Friends and Relatives
Hiking / Trekking
Camping
swimming
Boating / Sailing / Cruising
Diving
Destinations at high altitude

 Have you ever experienced one of the following conditions associated with travel?

 High altitude sickness
Traveler's diarrhea
Swelling related travel
Insomnia related travel

 Have you ever had one of the following conditions associated with travel?

 asthma
arthritis
blood clots
cancer
Chronic pulmonary disease
Coumadin Therapy
Pressure / Anxiety
diabetes
edema
Heart Disease
HIV / AIDS
immunosuppression
musculoskeletal injury
thymus disorder
tuberculosis

 Please list all of your medications, including prescription drugs, vitamins,
supplements and herbs:

 Do you take medications that suppress the immune system, such as prednisone, chemotherapy drugs, or drugs for rheumatoid arthritis and other autoimmune diseases?Are you allergic to any vaccines?

 Did you receive one of these vaccines, if so, when?

 chickenpox
Hepatitis A
Hepatitis B
Human papillomavirus (HPV)
flu
JE
Measles, mumps, rubella
meningococcus
pneumococcal
polio
rage
shingles
Tetanus and diphtheria
Tetanus, diphtheria and pertussis
typhoid
yellow fever