Ooltewah - Travel Vaccination Questionnaire

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Birthdate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Destination (country/cities) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date Of Trip {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you currently treated for any medical problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had a significant medical problem in the past {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Could you be pregnant {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you staying mostly in cities / tourist destinations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you going to spend time in a rural area {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you going to spend time above 5000 ft {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you allergic to eggs or chicken products {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had any hypersensitivity or reaction to vaccinations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had Guillain-Barre Syndrome {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you have all of your childhood vaccinations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you have tetanus/diphtheria vaccination in the last 10 years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you have polio vaccination as an adult {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you have hepatitis A vaccination (2 shots) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you have hepatitis B vaccination (3 shots) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you have meningitis vaccination in the past 3 years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you have yellow fever vaccination in the past 10 years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you have Japanese encephalitis vaccination in the past 2 years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

List current or previous significant medical conditions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List current medications {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List allergies {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Comments {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }