Traveler advice form, costs: €35Personal dataName: *Telephone number: Date of birth: Country of birth: Year of immigration: Accommodation: HotelAt familyWith local peopleElseReason for travel: HolidayFamily visitWorkElseRisk of activities: Stay >2500 metersWater sportSex/Tattoo/PiercingContact with animalsMedical proceduresElseE-mail address: 1. Country: Area / place name: Travel data from: Till 2. Country: Area / place name: Till Travel data from: 3. Country: Area / place name: Till Travel data from: Medical information:Are you suffering from a disease? yesnoDo you use medication? yesnoHave you been vaccinated as a child? in an older age? yesnoWhich vaccinations: Are you suffering froma depression? Other psychological problem? yesnoAre you allergic to something? yesnoDid you ever undergo surgery? (spleen removed?) yesnoAre you pregnant or planning in short-term pregnancy? yesnoHave any side effects from vaccination/malaria pill? yesnoEver had jaundice? yesnoDo you wear contact lenses? yesnoDo you have pacemaker or a vascular prosthesis? yesno By this I declare that I have completed this form truthfully. VerificationFill in two digits without spaces (example: 12) *Example: 12Deze ruimte is voor spam beveiliging - <strong>a.u.b. blanko laten</strong>:
