Back to travel indexChecklist for the traveller & Questionnaire

Obtain information on local conditions (Depending on destination)

Accidents related to:

Get the following check-ups

Subscribe to a medical insurance with appropriate cover abroad, i.e. accident, sickness, medical repatriation.

Predeparture medical questionnaire  ...  also NEVDGP 1 page pdf (with modifications)


First name:
Date of birth:

Country of origin:
Purpose of travel:
   q Private    q Professional
Special activities:
q Accommodation: e.g. camping, bivouac
q Sports: e.g. diving, hunting, high-altitude trekking

Date of departure and length of stay :

Places to be visited

Rural area
Yes      No
From                                  to          
Yes      No
From                                  to          
Yes      No
From                                 to          
Yes      No
From                                 to          
Yes      No
From                                 to          
 Medical history:
 Vaccination record:
 Current state of health:
 Chronic illnesses:
 Recent or current medical treatment:
 History of jaundice or hepatitis:
 Allergies (e.g. eggs, antibiotics, sulfonamides):
 For women: q Current pregnancy
q Pregnancy likely within 3 months
q Currently breastfeeding
 History of anxiety or depression:
q If yes, treatment prescribed (specify)
Neurological disorders (e.g. epilepsy, multiple sclerosis, etc.):
Cardiovascular disorders (e.g. thrombosis, use of pacemaker):