Travel Medicine & Vaccinations | North Carolina

Name

Sex

• Male
• Female

Birthdate

Phone

Email

Destination (country/cities)

Date Of Trip

Purpose Of Trip Please select Business Pleasure Other

Are you currently treated for any medical problems? Please select No Yes

Have you had a significant medical problem in the past? Please select No Yes

Could you be pregnant? Please select Yes No

Are you staying mostly in cities /​ tourist destinations? Please select No Yes

Are you going to spend time in a rural area? Please select Yes No

Are you going to spend time above 5000 ft? Please select No Yes

Are you going to work in the foreign country? Please select Yes No

Are you allergic to eggs or chicken products? Please select No Yes

Have you had any hypersensitivity or reaction to vaccinations? Please select Yes No

Have you had Guillain-Barre Syndrome? Please select No Yes

Have you had all of your childhood vaccinations? Please select Yes No

Have you had tetanus/​diphtheria vaccination in the last 10 years? Please select Yes No

Have you had a measles vaccination (2 shots)? Please select No Yes

Have you had a polio vaccination as an adult? Please select Yes No

Have you had a hepatitis A vaccination (2 shots)? Please select No Yes

Have you had a hepatitis B vaccination (3 shots)? Please select Yes No

Have you had a meningitis vaccination in the past 3 years? Please select Yes No

Have you had a typhoid vaccination in the past 2 years (if injected), or in the past 5 years (if oral)? Please select Yes No

Have you had a yellow fever vaccination in the past 10 years? Please select Yes No

Have you had a Japanese encephalitis vaccination in the past 2 years? Please select Yes No

List current or previous significant medical conditions

List current medications

List allergies

Comments