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Pre-Foreign Travel Information Form

Sex
PROPOSED COUNTRIES (Including Stop-overs):

Please list all the countries AND the regions of those countries. 
This is important for malaria medication

Expected accommodations at destination 1
Expected accommodations at destination 2
Expected accommodations at destination 3
Expected accommodations at destination 4
Expected accommodations at destination 5

Are you in close contact with anyone who has problems with their immune system?  (this includes people on chemotherapy)

Select an option
Have you had travel vaccines over the past 10 years?

Please list the vaccines you have had. 

(If you have a vaccine record books please bring these with you)

Do you know when you last received a tetanus vaccine?
Females
Are you Pregnant?
Please read the list of conditions below and select any one that you are getting treated for now, or in the past:

Thanks for submitting!

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