Health Declaration Form

Personal Information

Full Name *

Age as at Last Birthday *

Gender *

Male

Female

Nationality *

Passport Number *

Phone Number *

Nigerian or Foreign line

Email Address *

Confirm Email *

Emergency Contact / Next of Kin in Nigeria

Full Name *

Phone Number *

Nigerian or Foreign line

Travel Details

Departure Date *

Arrival Date *

Port of Entry *

Flight / Vessel / Vehicle Number *

International Airline *

Seat Number *

Transit Airport (optional)

Country of Residence *

Country of First Departure *

Transit Countries * (countries you passed through)

None / Direct Flight (no transit countries)

Countries Visited in Last 21 Days (all countries visited)

Purpose of Travel *

Destination State in Nigeria *

Destination Phone Number *

Nigerian or Foreign line

Destination Address in Nigeria *

Health Information

Please answer all health questions accurately. All information is strictly confidential.

In The Last 21 Days Did You Have any of the Following Signs or Symptoms?

Signs & Symptoms	Answer
Fever	Yes No
Cough	Yes No
Sneezing	Yes No
Generally feeling unwell	Yes No
Rashes	Yes No
Difficulty breathing	Yes No
Jaundice	Yes No
Nose/Ear bleeding	Yes No
Headache	Yes No
Body Aches	Yes No
Sore Throat	Yes No
Difficulty Swallowing	Yes No
Stomach Pain	Yes No
Vomiting	Yes No
Diarrhoea	Yes No
Lethargy	Yes No
Loss of Appetite	Yes No
Hiccup	Yes No
Other Symptoms	Yes No

In the Last 21 Days Have you Had Contact with Anyone Who Was Not Feeling Well with the Following?

Signs & Symptoms	Answer
Fever	Yes No
Cough	Yes No
Sneezing	Yes No
Generally feeling unwell	Yes No
Rashes	Yes No
Difficulty breathing	Yes No
Jaundice	Yes No
Nose/Ear bleeding	Yes No
Headache	Yes No
Body Aches	Yes No
Sore Throat	Yes No
Difficulty Swallowing	Yes No
Stomach Pain	Yes No
Vomiting	Yes No
Diarrhoea	Yes No
Lethargy	Yes No
Loss of Appetite	Yes No
Hiccup	Yes No
Other Symptoms	Yes No

Were you ill before boarding or during the trip?

Yes

Medication	Answer
Paracetamol, Ibuprofen, or any other pain relieving medication	Yes No
Antibiotics	Yes No
Antiviral Drugs	Yes No
Flu or common cold medication	Yes No
Anti Malaria	Yes No

Temperature Reading (°C) (if measured)

Vaccination Status *

Review & Submit

Please review all information carefully before submitting. Once submitted, you will receive a confirmation email with your declaration PDF.

By submitting this form, I declare that the information provided is true and correct to the best of my knowledge. I understand that providing false information is an offence under Nigerian law and is liable for prosecution. YOUR SUBMITTED FORM CAN'T BE EDITED, SO PLEASE REVIEW CAREFULLY BEFORE SUBMITTING.