Travel Medical Insurance Questionnaire
A travel medical insurance questionnaire is normally prepared by an insurance company and is used for gathering health related data of people who are planning to travel abroad. The data received helps an insurance company to offer a travel medical policy to their clients keeping in mind the various health advantages that their clients want to enjoy. The travel medical insurance questionnaire can contain questions related to both travel and medical aspects of their clients.
Sample Travel Medical Insurance Questionnaire:
Name of the Traveler: _____________________________
Date of Departure: ____________ Place of Departure: ____________________
Country of Arrival: _____________ Date of Arrival: _______________________
Date of Birth: ___________________ (MM/DD/YY) Gender: ___________ (M/F)
Phone Number: ____________________________
- Is this a business trip or a pleasure trip?
c) Others: ________________ (Please Specify)
- Have you had travel medical insurance before? If yes, then please specify insurance number and insurance agency.
c) Insurance Number: _________________________
d) Insurance Agency: _________________________
- What is the duration of your travel?
a) Less than 5 days
b) Less than 10 days
c) 10-15 days
d) 16-20 days
e) 21-30 days
f) More than a month
- Which destinations will you visit during this period?
a) Place#1: ______________________
b) Place#2: ______________________
c) Place#3: ______________________
- Have you administered relevant vaccinations required by the visiting country?
- Do you smoke?
c) Gave up recently
- Do you suffer from any of the following medical conditions?
a) High Blood Pressure
b) Low Blood Pressure
c) Elevated levels of Cholesterol
d) Diabetes Mellitus
e) Diabetes Insipidus
f) HIV / AIDS
g) Congenital Heart Disease
h) Hepatitis A, B, or C
- Do you suffer from any type of allergy? If yes, then please specify type and medication.
c) Type of allergy: _____________________________
d) Medication: _____________________________
Category: Travel Questionnaire