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International Travel Clinic Form

OCHD Travel Clinic Patient Questionnaire

Please fill out this questionnaire to the best of your ability. 
6. Will the trip be (check all that apply)? *This question is required.
7. Accommodations (check all that apply): *This question is required.
8. Do you have any medication allergies? *This question is required.
10. Are you pregnant or planning to become pregnant? *This question is required.
11. Are you breastfeeding? *This question is required.
12. Have you had any severe reactions to past vaccines? *This question is required.
15. Do you have any medical conditions, such as diabetes, heart disease, or lung disease? *This question is required.
17. Do you have sensitivity to sodium chloride, sorbitol or have been diagnosed with multiple sclerosis (MS)?
  *This question is required.
18. Are you allergic to gelatin? *This question is required.
19. Do you have sensitivity to yeast extract, casein, dextrose, galactose, sucrose, ascorbic acid, amino acids, lactose, or magnesium stearate? *This question is required.
20. Do you have an allergy to natural latex rubber? *This question is required.
21. Do you have sensitivity to protamine sulfate? *This question is required.
22. Do you have an allergy to thimerosal? *This question is required.
23. Do you have an allergy to yeast? *This question is required.
24. Do you have an allergy to neomycin? *This question is required.
25. Are you allergic to eggs or chicken protein? *This question is required.
26. Are you allergic to processed bovine gelatin, chlortetracycline, or amphotericin B? *This question is required.
27. Do you have sensitivity to phosphate or glutamate? *This question is required.
28. Are you immunosuppressed due to HIV, leukemia, lymphoma, thymic disease, generalized malignancy, corticosteroid therapy, alkylating drugs, antimetabolites, or radiation? *This question is required.
29. Do you have a history of thymus disease, myasthenia gravis, DIGeorge syndrome or thymoma? *This question is required.
30. Have you had removal of part of your intestine? *This question is required.
31. Are you taking sulfonamides or antibiotics?  *This question is required.
32. Are you currently experiencing an acute gastrointestinal illness? *This question is required.
33. Do you have a history of Guillian-Barre Syndrome? *This question is required.
34. Have you had a past reaction to pertussis (whooping cough) vaccine? *This question is required.
35. Do you have a history of a progressive neurologic disorder, uncontrolled epilepsy, or progressive encephalopathy?  *This question is required.
36. Do you have thrombocytopenia? *This question is required.
37. Do you desire anti-malarial medications? *This question is required.
38. Do you desire a prescription for the treatment of Traveler's Diarrhea? *This question is required.
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