Travel Vaccination Questionnaire

The primary area of focus in a travel vaccination questionnaire lies in revealing information regarding vaccinations taken by individuals when traveling internationally. Different countries in the world have different vaccination requirements like if you are traveling to the US then you should have taken influenza, tetanus, diptheria, varicella, zoster vaccines among others. The travel vaccination questionnaire is normally provided by a medical institution and should be filled prior to traveling to other countries.

Sample Travel Vaccination Questionnaire:

Name of the Traveler: _____________________________

Insurance Policy Number:_________________________________

Traveling to: _______________ (Country Name)

Traveling from: _________________ (Country of Origin)

Email: _____________________________

Phone Number: ____________________________

Date of Birth: ___________ Gender: _____ (M/F)

  • Are you currently planning pregnancy, pregnant, or breastfeeding?

a)      Yes

b)      No

  • What type of travel trip are you making?

a)      Business trip

b)      Travel and leisure

c)      Family holiday

d)     Trekking or mountaineering

e)      Backpacking

f)       Medical trip

g)      Educational trip

h)      Others: __________________ (Please Specify)

  • Which of the following vaccinations have you been administered before? (Please mention date of vaccination wherever possible)

a)      Tetanus

b)      Hepatitis B

c)      Diphtheria

d)     Meningitis ACWY

e)      Polio

f)       Rabies

g)      Tuberculosis

h)      Yellow Fever

i)        Hepatitis A

j)        Cholera

k)      Typhoid

l)        Japanese B Encephalitis

m)    Tick-borne Encephalitis

  • Have you been administered anti-malarial vaccines ever before? If yes then please specify when and if you suffered from any adverse reactions?

a)      Yes

b)      No

c)      Date of vaccination:____/_____/_______

d)     Adverse Reactions:________________________________________

  • Is your body weight over or under 45 kgs?

a)      Over

b)      Under

c)      Don’t Know

  • Are you allergic to any specific vaccination or medicine?

a)      Vaccination: ____________________________________

b)      Medicine: ____________________________________

c)      Other Allergies: __________________________________

Category: Travel Questionnaire

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