TRAVEL PLANS:
Itinerary
List ALL Countries and ALL Cites in order of visit
Include ANY stopovers in Africa or South America
Will you be:
Visiting areas that are:
Previous international travel:
HEALTH HISTORY (Check all that apply):
VACCINATION HISTORY
Have you received the following immunizations?
CURRENT MEDICATIONS
Prescription medications: List all current prescription medications
WARNING - if you use any form of Cannabis, be advised it is illegal in many foreign countries and you could be detained
QUESTIONS/CONCERNS
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