Travel Health Questionnaire

A travel health questionnaire can be used by organizations, medical institutions, travel agencies, insurance agencies and related organizations to find out information related to an individual’s health issues and current health conditions. Depending on the requirement, a travel health questionnaire can be very detailed in nature or just specific and concise. The information received from a travel health questionnaire is used for record keeping or for use by various agencies to customize health insurance covers.

Sample Travel Health Questionnaire:

Name of the Participant: _____________________________

Current Insurance Policy Number:_________________________________

Date of Departure: ____________ Place of Departure: ____________________

Date of Birth: ___________________ (MM/DD/YY) Gender: ___________ (M/F)

Address: ______________________________________  City:_______________

State: __________________  Zip: ________________

Email: _____________________________

Phone Number: ____________________________

  • When did you undergo your last health check-up?

a)      A few days back

b)      A week back

c)      Few weeks back

d)     A month back

e)      Few months back

f)       6 months back

g)      Last year

h)      Don’t remember

  • Do you suffer from any of the following medical conditions?

a)      Elevated cholesterol

b)      Chronic Inflammation

c)      Abnormal Blood Sugar Levels

d)     Pre-Diabetic

e)      Impaired Cellular Function

f)       Impaired Immune System

g)      Severe Acute Respiratory Syndrome (SARS)

h)      Rheumatoid Arthritis

i)        Congenital Heart Disease

j)        High Blood Pressure (Hypertension)

k)      Others: __________________ (Please Specify)

  • Have you administered any of the following vaccinations?

a)      Varicella

b)      Human papillomavirus (HPV)

c)      Tetanus, diphtheria, and acellular pertussis (Td/Tdap)

d)     Measles, mumps, rubella (MMR)

e)      Influenza

f)       Zoster

g)      Pneumococcal polysaccharide (PPSV)

h)      Meningococcal

i)        Hepatitis A

j)        Hepatitis B

  • Are you allergic to any of the following?

a)      Eggs

b)      Nylon

c)      Dust

d)     Microscopic substances

e)      Poison ivy and other plants

f)       Pet allergies

g)      Latex

h)      Drugs

i)        Nuts

j)        Fish

  • Do you have history of depression or anxiety?

a)      Yes

b)      No

Category: Travel Questionnaire

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