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)

 Surname: 

 
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

Country
Town
Rural area
Dates
 
   
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):
 

Source: www.who.int/ith/chapter01_04.html#checklist