Questionnaire & Order Form

THE TRAVEL DOCTOR
www.traveldoctor.co.uk

Questionnaire & Order Form

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From our experience of travel and adventure sports in different parts of the world, we have learned that the contents of your medical kit depends on various factors such as; the nature of your group, your destination and what activities you will be doing there.

This part of the website is designed to help you put together your own travel medical kit and help you use it appropriately:-

In order to do this, you will need to fill out the questionnaire below giving us details of you and your trip and then forward them to us.

We will then process this information and make available to you:-

A recommended list of medications to be obtained from your pharmacy.
A list to take to your GP to ask for his/her help in prescribing certain "Prescription Only Medicines".
A 36 page manual explaining how, when and why to use each medication.

The questionnaire follows a specific format and in order for us to provide you with your exact travel requirements you must follow the steps as outlined.

To avoid any mistakes please take a moment to familiarise yourself with the content of each question before continuing to the next one.

The information supplied will then be tailor-made to your own requirements.

Whether you are going on holiday to Spain for a couple of weeks or launching a full blown expedition to the summit of Everest, the list will be specific to your own requirements.

After successful completion of this part you will then be supplied with your customised medical list and manual.

You can now proceed to the questionnaire and fill in your details or, if you want further information about the Travel Doctor Manual click the following button:-

Welcome to the questionnaire . . . . . . .

In order for us to provide you with your exact travel requirements we first need you to follow the steps outlined below.

Please take a moment to familiarise yourself with the content of each step before continuing.

Once you have filled in the form giving your exact details click the "submit" button.

Your personalised list of travel medicine requirements will then be:

1. Displayed in your web browser for immediate printing.

2. E-mailed to you in the form of a web link of its location.

3. Stored on our site permitting you to access it again in the future.

Please note: there is a nominal charge of £5.00 for this service.

Step 1 - Supply your contact details:

Please fill in all the fields as the questionnaire requires this.

Title


First Name	Surname


Street Address


City/Town	County


Post Code	Telephone No.


E-mail address

Step 2 - Select your destination country:

Or click on the initial letter of your destination country to bring up a list of countries beginning with that letter in the dialog box.

Country:

Please Note: if you return to this page using your browser "Back" button before
completing the sign-up process, you MUST re-select your country of destination.
Otherwise the form will automatically reset and Afghanistan will be chosen by default
(being the first country alphabetically).

Step 3 - Specify your departure date and duration:

The duration of your trip is required to calculate the amounts of some of the medicines required.

Departure date:

and duration ( days )

Step 4 - Specify the number of people travelling in your party:

The number of persons in your group and the male/female ratio
has a direct bearing on the number and type of medicines required.

Specify the number of males
in your party:....

and the number of females
in your party:....

Step 5 - Select the main activity of your travel:

There is a list of activities to choose from in the dialog box below.
Since the number of possible activities runs into dozens it is not possible to list all of them, therefore, when selecting one, choose the one that is closest to the activity you propose to undertake. If you intend to undertake more than one activity, select the main (or most hazardous) activity.

Select your main activity:

Will you be trekking/climbing above 10,000ft/3,000m ?
Tick for yes.

Step 6 - Specify the anticipated number of days travel to the nearest hospital:

If someone in your party is injured during your trip and needs to be evacuated to hospital they will probably require medication whilst being transported. Therefore you should enter the maximum number of days travel to the nearest hospital in order for the computer to calculate sufficient quantities.

Anticipated maximum number of days travel from
the nearest hospital

Step 7 - Indicate if any members of the party are allergic to Penicillin:

If this is the case, no penicillin antibiotics will be selected for your list.

Any members of your party allergic to Penicillin?
Tick for yes.

Step 8 - Indicate where you heard about Travel Doctor:

For our market research department.

Where did you hear about Travel Doctor?

Web links Search engines Word of mouth Travel agent

Magazine ( if magazine please specify the title )

Step 9 - Submit your details for verification and processing or clear details:

Click on the submit button to activate the process.

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TRAVEL DOCTOR
www.traveldoctor.co.uk