EXPEDITION CONFIDENTIAL PRE-TRAVEL HEALTH QUESTIONNAIRE

Instructions: Please complete the questionnaire below. Please do not leave any fields
blank. Write ’N/A’ if not applicable.

PARTICIPANT PERSONAL DETAILS

Name:
Age:
Date of birth:
Gender:
Passport details – Number: Expiry date:
Address:
Contact phone number:

Details of guardian / parent (for students)

Name:
Address:
Phone number:

Details of 1st emergency contact

Name:
Address:
Phone number:

Details of 2nd emergency contact

Name:
Address:
Phone number:
Previous countries travelled to (if any):

Previous expedition trips (if any):

Previous mountaineering experience (if any) and altitude ascended to:

Previous First Aid training (if any) and details:

Can you swim? Yes / No (please circle)

Do you have swim lifesaver training? Yes / No (please circle)

Your role in this trip (student / teacher / parent-helper):

PARTICIPANT HEALTH QUESTIONNAIRE
National Health Identifier (NHI) number if known:

GP details
Name:
Practice name and address:
Practice phone number:

Have you undergone / do you plan to undergo pre-travel health consultation (highly
recommended)?
Yes / No (please circle)

I consent to my GP (and travel doctor) being contacted for purposes of information

regarding my health conditions:
Yes / No (please circle)

Travel insurance details

Insurer:
Policy number:
Policy type:

Current medications (prescription, over-the-counter, traditional / herbal remedies, creams,

oral contraceptives, inhalers):

Any additional medications planned for this trip (eg. malaria prevention):

Drug allergies / reactions if any, and details of the allergy / reaction:

Blood group (if known):

Please list if you currently suffer from / have suffered from health conditions related to –
Skin problems (eg. eczema, psoriasis)

Brain / nervous system problems (eg. epilepsy, migraines, brain / spinal surgery, brain injury,
brain aneurysms, loss of consciousness / fainting):

Eye problems (eg. glaucoma, retinal detachment, blindness, eye surgery):

Ear problems (eg. deafness, vertigo):

Breathing / lung problems (eg. asthma, pneumothorax, tuberculosis, pulmonary embolism,

lung surgery, smoking-related lung disease):

Heart or Blood vessel problems (eg. congenital heart disease, rheumatic heart fever, heart
surgery, abnormal heart rhythms, pacemaker, high blood pressure, heart attacks,
aneurysms):

Current and Ongoing Dental problems:

Gut / Abdominal / Liver problems (eg. heartburn, inflammatory bowel disease, coeliac
disease, hepatitis, abdominal surgery):

Kidney / bladder problems (eg. kidney stones, incontinence, long-term indwelling urinary
catheters, urine infections):

Joint / muscle problems (eg. arthritis, sports injuries, joint surgery):

Hormone / endocrine problems (eg. diabetes, thyroid disease, hormone deficiency):

Blood problems (eg. anemia, thalassemia, haemophilia, deep vein thrombosis, clotting
disorders, previous blood transfusions):
Genetic problems (eg. Trisomy 21):

Immune system problems (eg. food allergies, environmental allergies, anaphylaxis, immune
deficiencies, autoimmune diseases such as SLE):

Sleep problems (eg. obstructive sleep apnoea, night terrors, sleep-walking, bruxism):

Mental health / psychiatric / psychological problems (eg. mood disorders, schizophrenia,

obsessive-compulsive disorder, ADHD, eating disorder, self-harm, intentional drug
overdoses, anxiety, claustrophobia, specific phobias, anorexia nervosa):

Chronic infections (eg. HIV, viral hepatitis, latent TB):

Any mechanical implants / prostheses (eg. heart valve replacement, joint replacement):

Any malignancies / cancers:

Any special dietary requirements:

Any special needs (eg. wheelchair, communication difficulties, learning disabilities, CPAP
machine, medical assist devices):

Any previous travel / expedition-related illnesses (eg. altitude sickness, cold-related illness,
heat-related illness, motion-sickness):

Are you pregnant? Yes / No (please circle):

Any other previous surgeries:

Any other health conditions / issues / symptoms (that do not fall under above categories /
that you are currently seeking a doctor’s advice for):
Do you smoke? Yes / No (please circle). If so, how much / day?
Do you drink alcohol? Yes / No (please circle). If so, how often and how much?
If you use recreational drugs (eg. cannabis, amphetamines), please take note of the
penalties associated with possession at the transit / destination countries on your itinerary.

What is your height in cm?

What is your weight in kg?
What do you think your fitness level is (poor, average, above average, excellent)?

Do you engage in regular exercise / sports?

Yes / No (please circle)
If yes, what type of exercise / sports and how frequently?
Immunisation / Vaccination history
Are your childhood immunisations up to date?
Yes / no (please circle)

Date of most recent vaccination for following vaccines (if any)

Measles, mumps, rubella (MMR):
Diphtheria:
Tetanus:
Polio:
Pneumococcal:
Influenza:
Hepatitis B:
Meningococcal:
Typhoid:
BCG:
Hepatitis A:
Rabies:
Yellow fever*:
*please note that as the Expedition will travel through areas of Kenya which is endemic for Yellow Fever,
Tanzanian health authorities will require proof of Yellow Fever vaccination before entry.

Other travel vaccines you have had, but may not be relevant to this trip (eg.
Japanese B encephalitis):
Do you wish to be contacted to discuss specific health concerns for the upcoming trip?
Yes / No (please circle)
If yes, when is the best time to contact you:

I declare that the above is true and accurate to the best of my knowledge.
Name (parent / guardian if participant under 18 years of age)

Signature (parent / guardian if participant under 18 years of age)

Thank you for completing the above questionnaire. Please bring your own medications /
medical assist devices with you during the trip. We will be in contact if we require further
clarification.