The primary objective of a pre travel questionnaire is to gather relevant general, personal, travel, and medical information of individuals or a group of people who are travelling or planning to travel abroad. Different countries across the world have different medical and health requirements and the pre travel questionnaire takes this and other aspects into consideration.

Sample Pre Travel Questionnaire:

Name of the Traveler: _____________________________

Current Insurance Policy Number:_________________________________

Date of Departure: ____________ Place of Departure: ____________________

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

Email: _____________________________

Phone Number: ____________________________

  • Which of the following best describes your current travel or trip?

a)      Business

b)      Holiday

c)      Pleasure

d)     Medical

e)      Workshop/Conference

f)       High Altitude

g)      Educational

  • Which of the following vaccinations have you administered so far?

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

b)      Human papillomavirus (HPV)

c)      Varicella

d)     Measles, mumps, rubella (MMR)

e)      Zoster

f)       Pneumococcal polysaccharide (PPSV)

g)      Hepatitis A

h)      Hepatitis B

i)        Influenza

j)        Meningococcal

  • Do you have any history of allergy? If yes then please specify type of allergy

a)      Yes

b)      No

c)      Type of allergy:_____________________

  • Do you have any of the following severe medical conditions? (Please specify Yes/No)

a)      Epilepsy                                                    Yes | No

b)      Moderate to Severe depression                 Yes | No

c)      Morbid Obesity                                         Yes | No

d)     High Blood Pressure (Hypertension)        Yes | No

e)      High Cholesterol                                       Yes | No

f)       Temporary or permanent blindness           Yes | No

g)      Alzheimer’s Disease                                  Yes | No

h)      Hepatitis A, B, or C                                  Yes | No

  • Are you currently pregnant or breastfeeding?

a)      Yes

b)      No

  • Are you currently on any medication? If yes then please specify medication.

a)      Yes

b)      No

c)      Medication:______________________________



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