Confidential Medical Declaration Form

mission travel group
Confidential Medical Declaration Form
Name:
Date of birth:
Trip/tour name:
Departure date from Australia:
How physically fit are you?
POOR FAIR AVERAGE GOOD EXCELLENT
Please answer YES or No to the questions below. If you answer YES please provide details.
Have you ever had fainting spells? YES NO
Do you have any physical impairments/disabilities? YES NO
Do you have any mental impairments/disabilities? YES NO
Do you have any allergies? YES NO
Are you on a special diet? YES NO
Do you have or have you had sleep walking episodes? YES NO
Do you have or have you had sleep apnoea? YES NO
Do you get nervous, anxious or upset easily? YES NO
Do you have or have you been treated for anxiety/depression? YES NO
3/400 Canterbury Road Surrey Hills, VIC. 3127 P: (03) 9836 7199 or 1300 554 654 E: info@missiontravel.com.au
www.missiontravel.com.au

mission travel group
Do you have any phobias? YES NO
Do you or have you ever had a seizure disorder? YES NO
Do you have or have you ever had breathing difficulties? YES NO
Do you have or have you had any heart related health issues? YES NO
Do you have diabetes or hypoglycaemia? YES NO
Do you have any circulatory issues or difficulty walking? YES NO
Have you ever had a DVT (deep vein thrombosis)? YES NO
Have you had any significant past surgery or illness? YES NO
If you answered YES to any of the above, please provide your doctor’s name and contact details:
3/400 Canterbury Road Surrey Hills, VIC. 3127 P: (03) 9836 7199 or 1300 554 654 E: info@missiontravel.com.au
www.missiontravel.com.au

mission travel group
Are you currently on medication? YES NO
If so what is the medication, the condition being treated, the dosage and how often it is taken?
Do you have any other medical conditions that we should be aware of?
I
,declare that the information provided here is correct.
(Full Name)
I understand that Mission Travel Group and its suppliers reserve the right to deem me medically unfit to
travel prior to, or during travel, based on the information declared.
Travel insurance is strongly recommended at the time of booking. Answering YES to any of these
questions may deem you to have a “pre-existing medical condition” which may require additional cover or
denial of cover.
I agree
Full Name:
Date:
3/400 Canterbury Road Surrey Hills, VIC. 3127 P: (03) 9836 7199 or 1300 554 654 E: info@missiontravel.com.au
www.missiontravel.com.au