Traveler advice formTraveler advice costs: €30Personal dataName *Telephone number E-mail address Date of birth Country of birth: Year of immigration: Reason for travel: HolidayFamily visitWorkElseAccommodation: HotelAt familyWith local peopleElseRisk of activities: Stay >2500 metersWater sportSex/Tattoo/PiercingContact with animalsMedical proceduresElseDestination (s)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>:
