Ooltewah - Travel Vaccination Questionnaire

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Sex
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Are you currently treated for any medical problems
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Have you had a significant medical problem in the past
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Could you be pregnant
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Are you staying mostly in cities / tourist destinations
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Are you going to spend time in a rural area
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Are you going to spend time above 5000 ft
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Are you allergic to eggs or chicken products
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Have you had any hypersensitivity or reaction to vaccinations
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Have you had Guillain-Barre Syndrome
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Did you have all of your childhood vaccinations
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Did you have tetanus/diphtheria vaccination in the last 10 years
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Did you have polio vaccination as an adult
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Did you have hepatitis A vaccination (2 shots)
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Did you have hepatitis B vaccination (3 shots)
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Did you have meningitis vaccination in the past 3 years
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Did you have yellow fever vaccination in the past 10 years
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Did you have Japanese encephalitis vaccination in the past 2 years
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Ooltewah - Travel Vaccination Questionnaire

Ooltewah - Travel Vaccination Questionnaire

Name
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Sex
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Birthdate
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Phone
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Email
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Destination (country/cities)
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Date Of Trip
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Purpose Of Trip
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Are you currently treated for any medical problems
{binding displayValue}
Have you had a significant medical problem in the past
{binding displayValue}
Could you be pregnant
{binding displayValue}
Are you staying mostly in cities / tourist destinations
{binding displayValue}
Are you going to spend time in a rural area
{binding displayValue}
Are you going to spend time above 5000 ft
{binding displayValue}
Are you allergic to eggs or chicken products
{binding displayValue}
Have you had any hypersensitivity or reaction to vaccinations
{binding displayValue}
Have you had Guillain-Barre Syndrome
{binding displayValue}
Did you have all of your childhood vaccinations
{binding displayValue}
Did you have tetanus/diphtheria vaccination in the last 10 years
{binding displayValue}
Did you have polio vaccination as an adult
{binding displayValue}
Did you have hepatitis A vaccination (2 shots)
{binding displayValue}
Did you have hepatitis B vaccination (3 shots)
{binding displayValue}
Did you have meningitis vaccination in the past 3 years
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Did you have typhoid vaccination in the past 2 years (if injected), or in the past 5 years (if oral)
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Did you have yellow fever vaccination in the past 10 years
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Did you have Japanese encephalitis vaccination in the past 2 years
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List current or previous significant medical conditions
List current medications
List allergies
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