Travel Clinic Survey
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Full legal name
Date of Birth
Street Address
Apt./Unit
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip Code
Email address
Mobile Phone Number
List the countries/cities you will be visiting, in order of arrival. Include all airports and any scheduled layovers. The United States will be your country of origin.
What date will you be leaving the United States?
What date will you be returning to the United States?
Your travel will primarily be:
Urban
Rural
Both
Please identify your travel accommodations. Check all that apply:
Hotel
Camp/Tent
Dormitory
Ship
Private Residence/Home
Are you allergic to any medications?
Yes
No
Please list all medications you are allergic to, and what kind of reaction you experience:
List all medication you are currently taking, either prescriptions or over-the-counter (answer "N/A" if you are not currently taking any medications):
Are you pregnant or planning to become pregnant?
Yes
No
Not applicable
Are you breastfeeding?
Yes
No
Not applicable
Have you had any severe reactions to past vaccines?
Yes
No
Not applicable
Please list all vaccines that have caused severe reactions, and the type of reactions you experienced:
Do you have, or have you had a history with, any of the following medical conditions?
Diabetes
Heart Disease
Lung Disease
Guillain-Barre Syndrome
Progressive Neurologic Disorder
Uncontrolled Epilepsy
Thrombocytopenia
Thymus Disease
Myashenia Gravis
DiGeorge Syntrome
Thymoma
Other
None of these
If you selected "Other", list here:
Do you have an allergy/sensitivity to any of the following? Check all that apply:
Sodium Chloride
Sorbitol
Gelatin
Yeast Extract
Casein
Dextrose
Galactose
Sucrose
Ascorbic Acid
Amino Acids
Lactose
Magnesium Stearate
Natural Latex Rubber
Protamine Sulfate
Thimerosal
Yeast
Neomycin
Eggs/Chicken Protein
Processed Bovine Gelatin
Chlortetracycline
Amphotericin B
Phosphate
Glutamate
Other
None of these
If you selected "Other", list here:
Are you immunosuppressed due to any of the following? Check all that apply:
HIV
Leukemia
Lymphoma
Thymic Disease
GeneralizedMalignancy
Corticosteroid Therapy
Alkylating Drugs
Antimetabolites
Radiation
Other
None of these
If you selected "Other", list here:
Are you taking sulfonamides or antibiotics?
Yes
No
Unknown
Are you currently experiencing an acute gastrointestinal illness?
Yes
No
Unknown
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