Backpacker Tourist Medical Information Declaration Form
Full Name
Passport Number
Date of Birth
Nationality
Emergency Contact Name & Number
Do you have any existing medical conditions?
Yes
No
If yes, please specify
Do you have any allergies?
Yes
No
If yes, please specify
Are you currently taking any medications?
Yes
No
If yes, please specify
Are your routine vaccinations up to date?
Yes
No
Do you have any special needs or requirements?
Additional notes or information